Provider Demographics
NPI:1811933955
Name:HENNINGER, JARED R (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:R
Last Name:HENNINGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 N DUKE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2374
Mailing Address - Country:US
Mailing Address - Phone:717-544-4995
Mailing Address - Fax:
Practice Address - Street 1:540 N DUKE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2374
Practice Address - Country:US
Practice Address - Phone:717-544-4995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052424363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACA067780Medicare ID - Type UnspecifiedMEDICARE GROUP #
PAQ59818Medicare UPIN