Provider Demographics
NPI:1457485112
Name:RENNINGER, JENNIFER C (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:RENNINGER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W. OAK STREET
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931
Mailing Address - Country:US
Mailing Address - Phone:570-874-4100
Mailing Address - Fax:570-874-1730
Practice Address - Street 1:701 W. OAK STREET
Practice Address - Street 2:
Practice Address - City:FRACKVILLE
Practice Address - State:PA
Practice Address - Zip Code:17931
Practice Address - Country:US
Practice Address - Phone:570-874-4100
Practice Address - Fax:570-874-1730
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA124682G7GMedicare PIN