Provider Demographics
NPI:1083684062
Name:WELLER, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S 7TH AVE
Mailing Address - Street 2:SUITE 3020
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1410
Mailing Address - Country:US
Mailing Address - Phone:610-375-6147
Mailing Address - Fax:610-378-9967
Practice Address - Street 1:301 S 7TH AVE
Practice Address - Street 2:SUITE 3020
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1410
Practice Address - Country:US
Practice Address - Phone:610-375-6147
Practice Address - Fax:610-378-9967
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003304L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMW0613213Medicaid
PAP16134Medicare UPIN