Provider Demographics
NPI:1053724146
Name:HANEY, JENNIFER (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:HANEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7017
Mailing Address - Country:US
Mailing Address - Phone:540-951-1111
Mailing Address - Fax:
Practice Address - Street 1:3700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7017
Practice Address - Country:US
Practice Address - Phone:540-951-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102205079207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program