Healthcare Provider Details

I. General information

NPI: 1376655704
Provider Name (Legal Business Name): JENNA ALANE HIESTAND MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-956-9711
  • Fax:
Mailing address:
  • Phone: 315-956-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number307264
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2006-01125
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number40971
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number103380
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD27977
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: