Provider Demographics
NPI:1912013467
Name:HENNINGER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HENNINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 S LINCOLN AVE
Mailing Address - Street 2:BELLWOOD OFFICE
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-1349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:863 S LINCOLN AVE
Practice Address - Street 2:BELLWOOD OFFICE
Practice Address - City:TYRONE
Practice Address - State:PA
Practice Address - Zip Code:16686-1349
Practice Address - Country:US
Practice Address - Phone:814-684-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009583L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA023685SFTMedicare ID - Type Unspecified
PAG86767Medicare UPIN