Provider Demographics
NPI:1124761317
Name:EWALD, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EWALD
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:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:WERNERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19565-0119
Mailing Address - Country:US
Mailing Address - Phone:610-750-9447
Mailing Address - Fax:610-750-9383
Practice Address - Street 1:60A WERNER ST
Practice Address - Street 2:
Practice Address - City:WERNERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19565-1623
Practice Address - Country:US
Practice Address - Phone:610-750-9447
Practice Address - Fax:610-750-9383
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PC006149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty