Basic Information
Provider Information | |||||||||
NPI: | 1710075932 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRICK | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ZEOLLA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 430 INNOVATION DRIVE | ||||||||
Address2: |   | ||||||||
City: | BLAIRSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 157178096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7243434060 | ||||||||
FaxNumber: | 7243434069 | ||||||||
Practice Location | |||||||||
Address1: | 1601 UNION AVENUE, PLAZA ONE | ||||||||
Address2: | SUITE D | ||||||||
City: | NATRONA HEIGHTS | ||||||||
State: | PA | ||||||||
PostalCode: | 15065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7242245090 | ||||||||
FaxNumber: | 7242245093 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2006 | ||||||||
LastUpdateDate: | 01/14/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT007899L | PA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 116946 | 01 | PA | HEALTH AMER/HEALTH ASSUR. | OTHER | 7759646 | 01 | PA | AETNA | OTHER | 000679044 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |