Provider Demographics
NPI:1003144882
Name:FENNER, JESSICA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:FENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 OAK LEAF LANE
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301
Mailing Address - Country:US
Mailing Address - Phone:570-242-8876
Mailing Address - Fax:
Practice Address - Street 1:175 E BROWN ST
Practice Address - Street 2:SUITE 115
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-424-7764
Practice Address - Fax:570-421-0760
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant