Provider Demographics
NPI:1942067343
Name:PAUCHFENTON, JACQUELINE LOUISE (MED)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LOUISE
Last Name:PAUCHFENTON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LOUISE
Other - Last Name:PAUCH-FENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED
Mailing Address - Street 1:172 N SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-9227
Mailing Address - Country:US
Mailing Address - Phone:724-977-7513
Mailing Address - Fax:
Practice Address - Street 1:172 N SUMMIT RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-9227
Practice Address - Country:US
Practice Address - Phone:724-977-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002581103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty