Provider Demographics
NPI:1124130596
Name:JESSELL, MARTHA A
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:JESSELL
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 1:900 BRYAN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2413
Mailing Address - Country:US
Mailing Address - Phone:814-643-6300
Mailing Address - Fax:814-643-8776
Practice Address - Street 1:900 BRYAN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2413
Practice Address - Country:US
Practice Address - Phone:814-643-6300
Practice Address - Fax:814-643-8776
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001242101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA399222OtherVALUE OPTIONS
PA1469457OtherBLUE SHIELD (MANAGED CARE