Provider Demographics
NPI:1457423220
Name:HANEY, JEFFREY S (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:HANEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:607 DEMERS AVE - ALTRU CLINIC / EAST GRAND FORKS
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721
Practice Address - Country:US
Practice Address - Phone:218-773-0357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND718225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25228OtherBLUE SHIELD