Provider Demographics
NPI:1114365194
Name:STOCKHAUSEN, JENNIFER LAURA (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAURA
Last Name:STOCKHAUSEN
Suffix:
Gender:F
Credentials:DO
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 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:3691 CRESCENT CT E
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-3433
Practice Address - Country:US
Practice Address - Phone:610-434-9561
Practice Address - Fax:610-434-5122
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018779207Q00000X
VA0102203959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine