Provider Demographics
NPI:1861479792
Name:DOUGLAS, JENNIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:SHAULIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6521 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:DELMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15626-2402
Mailing Address - Country:US
Mailing Address - Phone:724-468-8764
Mailing Address - Fax:724-468-8785
Practice Address - Street 1:6521 ROUTE 22
Practice Address - Street 2:
Practice Address - City:DELMONT
Practice Address - State:PA
Practice Address - Zip Code:15626-2402
Practice Address - Country:US
Practice Address - Phone:724-468-8764
Practice Address - Fax:724-468-8785
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422567207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013584800003Medicaid
PAI16831Medicare UPIN
PA1013584800003Medicaid