Provider Demographics
NPI:1164562492
Name:MABOLD, JENNIFER LYNN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MABOLD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 GLADE RUN RD
Mailing Address - Street 2:
Mailing Address - City:EVANS CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16033-7720
Mailing Address - Country:US
Mailing Address - Phone:724-586-1192
Mailing Address - Fax:
Practice Address - Street 1:5115 CENTRE AVE FL 2
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1301
Practice Address - Country:US
Practice Address - Phone:412-692-2606
Practice Address - Fax:412-692-2610
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006405B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA074050HOSMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAQ03277Medicare UPIN