Healthcare Provider Details

I. General information

NPI: 1992042840
Provider Name (Legal Business Name): JENNA ELIZABETH HAFNER PA- C, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA ELIZABETH HUMPHREYS

II. Dates (important events)

Enumeration Date: 01/12/2013
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3757 CARMAN RD STE 100
SCHENECTADY NY
12303-5438
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD STE 203
LATHAM NY
12110-2461
US

V. Phone/Fax

Practice location:
  • Phone: 518-355-7063
  • Fax: 518-357-0646
Mailing address:
  • Phone: 518-782-3700
  • Fax: 518-782-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110004150
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number019274-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: