Provider Demographics
NPI:1891393237
Name:VILLANO, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VILLANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:SIMPSON
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1104
Mailing Address - Country:US
Mailing Address - Phone:157-028-1256
Mailing Address - Fax:
Practice Address - Street 1:C/O SCI WAYMART
Practice Address - Street 2:
Practice Address - City:WAYMART
Practice Address - State:PA
Practice Address - Zip Code:18472
Practice Address - Country:US
Practice Address - Phone:570-488-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOtherSTATE CORRECTIONS INSURANCE