Provider Demographics
NPI:1194360230
Name:NIETO, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:NIETO
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 392573
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-9573
Mailing Address - Country:US
Mailing Address - Phone:410-208-3630
Mailing Address - Fax:
Practice Address - Street 1:11070 CATHELL RD STE 7
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-9344
Practice Address - Country:US
Practice Address - Phone:410-208-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27673225100000X
DEJ1-0004168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty