Basic Information
Provider Information | |||||||||
NPI: | 1124698824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SELEMBA | ||||||||
FirstName: | JORDAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHMUCK | ||||||||
OtherFirstName: | JORDAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 769 ARTHUR ST | ||||||||
Address2: |   | ||||||||
City: | FREELAND | ||||||||
State: | PA | ||||||||
PostalCode: | 182241202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708550830 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 BROOKHILL SQ S | ||||||||
Address2: |   | ||||||||
City: | SUGARLOAF | ||||||||
State: | PA | ||||||||
PostalCode: | 182491016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708023099 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2021 | ||||||||
LastUpdateDate: | 06/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.