Provider Demographics
NPI:1003989765
Name:FENTER, JERRY ED (MPT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ED
Last Name:FENTER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 I 55 SERVICE RD
Mailing Address - Street 2:STE C
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364
Mailing Address - Country:US
Mailing Address - Phone:870-739-8686
Mailing Address - Fax:870-739-8656
Practice Address - Street 1:2860 I 55 SERVICE RD
Practice Address - Street 2:STE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-739-8686
Practice Address - Fax:870-739-8656
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR920842873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159618721Medicaid
AR5Y625Medicare PIN