Provider Demographics
NPI:1124600093
Name:HATHAWAY, JENNIFER CHRISTINE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:HATHAWAY
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 1:717 DELAWARE ST SE STE 353
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2959
Mailing Address - Country:US
Mailing Address - Phone:612-626-3761
Mailing Address - Fax:
Practice Address - Street 1:717 DELAWARE ST SE STE 353
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2959
Practice Address - Country:US
Practice Address - Phone:612-626-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNX000-057-306-400390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty