Provider Demographics
NPI:1841436953
Name:WENNBERG, JENS L (PA)
Entity type:Individual
Prefix:MR
First Name:JENS
Middle Name:L
Last Name:WENNBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MIDLINE RD
Mailing Address - Street 2:
Mailing Address - City:FREEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13068-5625
Mailing Address - Country:US
Mailing Address - Phone:607-539-7733
Mailing Address - Fax:
Practice Address - Street 1:501 MIDLINE RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-5625
Practice Address - Country:US
Practice Address - Phone:607-539-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004990363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical