Healthcare Provider Details

I. General information

NPI: 1609802461
Provider Name (Legal Business Name): JENNIFER LEE BRILLHART PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN BRILLHART PAC

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 05/19/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MONUMENT STREET STE 1100
YORK PA
17403-1740
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-6454
  • Fax: 717-851-1665
Mailing address:
  • Phone: 717-851-6454
  • Fax: 717-851-1665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA002018L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA002018L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA002018L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: