Provider Demographics
NPI:1588628424
Name:WHITE, JENNIFER DYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DYAN
Last Name:WHITE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 WARREN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-3443
Mailing Address - Country:US
Mailing Address - Phone:814-255-2220
Mailing Address - Fax:814-255-2218
Practice Address - Street 1:322 WARREN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-3443
Practice Address - Country:US
Practice Address - Phone:814-255-2220
Practice Address - Fax:814-255-2218
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007175L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007210Medicare ID - Type UnspecifiedPROVIDER NUMBER