Provider Demographics
NPI:1053633131
Name:IANNUZZELLI, JENA ELISE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENA
Middle Name:ELISE
Last Name:IANNUZZELLI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2615
Mailing Address - Country:US
Mailing Address - Phone:610-565-0515
Mailing Address - Fax:610-566-4141
Practice Address - Street 1:331 W STATE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2615
Practice Address - Country:US
Practice Address - Phone:610-565-0515
Practice Address - Fax:610-566-4141
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016444103TC0700X
DEB1-0000783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical