Provider Demographics
NPI:1124600093
Name:HATHAWAY, JENNIFER CHRISTINE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNX000-057-306-400390200000X
MN76819208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty