Provider Demographics
NPI:1164507257
Name:MOREHOUSE, JENNIFER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MOREHOUSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E PLEASANT VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-6807
Mailing Address - Country:US
Mailing Address - Phone:814-946-8189
Mailing Address - Fax:814-943-4885
Practice Address - Street 1:31 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW KINGSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17072-9800
Practice Address - Country:US
Practice Address - Phone:814-946-8189
Practice Address - Fax:814-943-4885
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS 035272122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA*0019737170001Medicaid