Provider Demographics
NPI:1457859050
Name:MACEJKOVIC, JENNIFER (RDH, BS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MACEJKOVIC
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1828
Mailing Address - Country:US
Mailing Address - Phone:570-343-2383
Mailing Address - Fax:570-343-3923
Practice Address - Street 1:5 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JERMYN
Practice Address - State:PA
Practice Address - Zip Code:18433-1121
Practice Address - Country:US
Practice Address - Phone:570-383-9934
Practice Address - Fax:570-230-0023
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000975124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADH073107OtherLICENSE