Provider Demographics
NPI:1962475681
Name:PENNOCK, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HOLST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11676 PERRY HWY STE 1308
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8758
Mailing Address - Country:US
Mailing Address - Phone:724-933-0155
Mailing Address - Fax:412-578-5902
Practice Address - Street 1:11676 PERRY HWY
Practice Address - Street 2:SUITE 1308
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-1509
Practice Address - Country:US
Practice Address - Phone:724-933-0155
Practice Address - Fax:724-933-0833
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426226207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00737053OtherRR MCR
PA1544955OtherGATEWAY
PA000000275550OtherUNISON
PA410620OtherUPMC HEALTH PLAN
PA101269432Medicaid
PA1065756OtherHEALTH AMERICA
PA1736097OtherHIGHMARK BCBS
PAP00737053OtherRR MCR
PAI26217Medicare UPIN