Provider Demographics
NPI:1245613926
Name:JULSTEDT, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JULSTEDT
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 1:28 RUBANDO DR
Mailing Address - Street 2:
Mailing Address - City:SPRING BROOK TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-6430
Mailing Address - Country:US
Mailing Address - Phone:570-335-3744
Mailing Address - Fax:
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1782
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:570-558-6838
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008207101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional