Provider Demographics
NPI:1154849438
Name:HAFNER, JESSICA KRISTIE (ATC/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KRISTIE
Last Name:HAFNER
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 GALAXY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2187
Mailing Address - Country:US
Mailing Address - Phone:989-400-6083
Mailing Address - Fax:
Practice Address - Street 1:508 GALAXY WAY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2187
Practice Address - Country:US
Practice Address - Phone:989-400-6083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12032255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer