Provider Demographics
NPI:1760717144
Name:PICCOLOMINI, JENNA ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:ANN
Last Name:PICCOLOMINI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 RIDGEVIEW DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:15478-1650
Mailing Address - Country:US
Mailing Address - Phone:724-569-8100
Mailing Address - Fax:724-569-8368
Practice Address - Street 1:100 RIDGEVIEW DR UNIT 3
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:PA
Practice Address - Zip Code:15478
Practice Address - Country:US
Practice Address - Phone:724-569-8100
Practice Address - Fax:724-569-8368
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440031OtherPROMISE GROUP #