Provider Demographics
NPI:1952510455
Name:WOOLISCROFT, JAN AMBOYER (MA)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:AMBOYER
Last Name:WOOLISCROFT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201B WATERFORD ST
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2226
Mailing Address - Country:US
Mailing Address - Phone:814-734-7094
Mailing Address - Fax:814-734-3080
Practice Address - Street 1:201B WATERFORD ST
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-2226
Practice Address - Country:US
Practice Address - Phone:814-734-7094
Practice Address - Fax:814-734-3080
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005713L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR05336Medicare UPIN