Provider Demographics
NPI:1992042840
Name:HAFNER, JENNA ELIZABETH (PA- C, DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH
Last Name:HAFNER
Suffix:
Gender:F
Credentials:PA- C, DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:ELIZABETH
Other - Last Name:HUMPHREYS
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 1:3757 CARMAN RD STE 100
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-5438
Practice Address - Country:US
Practice Address - Phone:518-355-7063
Practice Address - Fax:518-357-0646
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004150363AM0700X
NY019274-1363AM0700X
NY019274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04313920Medicaid