Healthcare Provider Details

I. General information

NPI: 1457423220
Provider Name (Legal Business Name): JEFFREY S HANEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 DEMERS AVE - ALTRU CLINIC / EAST GRAND FORKS
EAST GRAND FORKS MN
56721
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 218-773-0357
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number718
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: