Provider Demographics
NPI:1538246053
Name:JOHANNES, JENNIFER LEE (ATC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:JOHANNES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:185 BEACH STREET
Mailing Address - City:BLANCHARD
Mailing Address - State:PA
Mailing Address - Zip Code:16826-0157
Mailing Address - Country:US
Mailing Address - Phone:570-962-3440
Mailing Address - Fax:
Practice Address - Street 1:101 REGENT CT
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7965
Practice Address - Country:US
Practice Address - Phone:800-505-2101
Practice Address - Fax:814-231-1319
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0040102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer