=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700460433
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIE FECSEN AA;CPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2021
-----------------------------------------------------
Last Update Date | 05/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 HUFF AVE
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-5382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-523-9668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 PENN AVE
-----------------------------------------------------
City | WILKINSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15221-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-523-9668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 14205
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------