Provider Demographics
NPI:1851849830
Name:WEINER, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WEINER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ORANGE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5817
Mailing Address - Country:US
Mailing Address - Phone:917-929-5671
Mailing Address - Fax:
Practice Address - Street 1:200 S ORANGE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:973-322-7020
Practice Address - Fax:973-322-7039
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020166363AS0400X
NJ25MP00422900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical