Provider Demographics
NPI:1629044979
Name:KOEHLER, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:KOEHLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-2170
Practice Address - Country:US
Practice Address - Phone:570-271-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q45644Medicare UPIN
PA091756Medicare ID - Type Unspecified