Basic Information
| Provider Information | |||||||||
| NPI: | 1760688204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNAVELY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BRAE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | STATE COLLEGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168014623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142069944 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 11/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OT011584 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0S014357 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 130267 | 01 | PA | GEISSINGER | OTHER | SN2128627 | 01 | PA | HIGHMARK | OTHER | 102398784-0001 | 05 | PA | MEDICAID | 413602 | 01 | PA | UPMC | OTHER |