Provider Demographics
NPI:1265052005
Name:FRATTARELLI, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FRATTARELLI
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 1:380 BUCHERT RD
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-1002
Mailing Address - Country:US
Mailing Address - Phone:847-293-6420
Mailing Address - Fax:
Practice Address - Street 1:1000 GRAVEL PIKE STE 100
Practice Address - Street 2:
Practice Address - City:SCHWENKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19473-2364
Practice Address - Country:US
Practice Address - Phone:847-293-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-20-40572103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1-20-40572Medicaid
PA1-20-40572OtherANY