Provider Demographics
NPI:1437142460
Name:LANDES, JENNIFER MAE (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MAE
Last Name:LANDES
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 1111
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-0907
Mailing Address - Country:US
Mailing Address - Phone:215-453-4995
Mailing Address - Fax:215-453-4646
Practice Address - Street 1:99 N WEST END BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951-1272
Practice Address - Country:US
Practice Address - Phone:215-536-3200
Practice Address - Fax:215-536-3259
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-04-07
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
PAOS010336L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014139480003Medicaid
PAH89854Medicare UPIN
PA1014139480003Medicaid