Provider Demographics
NPI:1992357487
Name:RETALLACK, JOLENE VERONICA
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:VERONICA
Last Name:RETALLACK
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 1:409 SUSQUEHANNA ST
Mailing Address - Street 2:
Mailing Address - City:TREVORTON
Mailing Address - State:PA
Mailing Address - Zip Code:17881-1209
Mailing Address - Country:US
Mailing Address - Phone:570-850-3936
Mailing Address - Fax:
Practice Address - Street 1:350 N 11TH ST
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1611
Practice Address - Country:US
Practice Address - Phone:570-286-3570
Practice Address - Fax:570-286-3322
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008974225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist