Provider Demographics
NPI:1548754468
Name:VANDENBURGH, JENNIFER ANNE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:VANDENBURGH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:939 ROUTE 146 STE 700
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3662
Practice Address - Country:US
Practice Address - Phone:518-383-0891
Practice Address - Fax:518-383-1662
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05205601Medicaid