Provider Demographics
NPI:1184187064
Name:HODGE-STANGROOM, JENNIFER R
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:HODGE-STANGROOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 WALNUT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-7300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 WALNUT ST STE 1
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132-7300
Practice Address - Country:US
Practice Address - Phone:724-331-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN606607163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse