Provider Demographics
NPI:1245335660
Name:ILLIG, JENNIFER M (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:ILLIG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1850 E PARK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6706
Mailing Address - Country:US
Mailing Address - Phone:844-278-4600
Mailing Address - Fax:814-235-1133
Practice Address - Street 1:1850 E PARK AVE STE 201
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6706
Practice Address - Country:US
Practice Address - Phone:844-278-4600
Practice Address - Fax:814-235-1133
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052572363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical