Provider Demographics
NPI:1124165253
Name:VAETH, JENNA CALABRESE (PT)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:CALABRESE
Last Name:VAETH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 MICHAEL DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9276
Mailing Address - Country:US
Mailing Address - Phone:716-348-8734
Mailing Address - Fax:716-741-9658
Practice Address - Street 1:5435 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3609
Practice Address - Country:US
Practice Address - Phone:716-348-8734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0267691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000628037002OtherBCBS
NY9312827OtherINDEPENDENT HEALTH
NY00027084302OtherUNIVERA
NYRA8760Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #