Healthcare Provider Details

I. General information

NPI: 1972452795
Provider Name (Legal Business Name): JENNA LYN HALE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 01/26/2026
Certification Date: 01/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3835 N FALLS RD
BURDETT NY
14818-9639
US

IV. Provider business mailing address

3835 N FALLS RD
BURDETT NY
14818-9639
US

V. Phone/Fax

Practice location:
  • Phone: 607-377-6766
  • Fax:
Mailing address:
  • Phone: 607-377-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number006418-02
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number017437-03
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: