Provider Demographics
NPI:1043761307
Name:HAWTHORN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HAWTHORN
Suffix:
Gender:F
Credentials:
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 434
Mailing Address - Street 2:
Mailing Address - City:MARIENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16239-0434
Mailing Address - Country:US
Mailing Address - Phone:814-927-8700
Mailing Address - Fax:814-927-8142
Practice Address - Street 1:120 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MARIENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16239-0434
Practice Address - Country:US
Practice Address - Phone:814-927-8700
Practice Address - Fax:814-927-8142
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP038362L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist