Provider Demographics
NPI:1457395055
Name:STULL, JENNIFER CAREY (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAREY
Last Name:STULL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2529
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:4000 STERRETTANIA RD UPPR LEVEL
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4125
Practice Address - Country:US
Practice Address - Phone:814-835-6640
Practice Address - Fax:814-835-6649
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S013868207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017397170001Medicaid
125231Medicare UPIN
PA1017397170001Medicaid