Basic Information
Provider Information | |||||||||
NPI: | 1699150441 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENRY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 ST LUKES BLVD | ||||||||
Address2: |   | ||||||||
City: | EASTON | ||||||||
State: | PA | ||||||||
PostalCode: | 180455671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4845034500 | ||||||||
FaxNumber: | 4845034501 | ||||||||
Practice Location | |||||||||
Address1: | 600 COMMERCE BLVD | ||||||||
Address2: |   | ||||||||
City: | STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 183606214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704262700 | ||||||||
FaxNumber: | 5704241252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2015 | ||||||||
LastUpdateDate: | 08/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP015108 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | SP015108 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
No ID Information.