Provider Demographics
NPI:1073963351
Name:FORTNEY, JENIFER KAY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JENIFER
Middle Name:KAY
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7140
Mailing Address - Country:US
Mailing Address - Phone:217-508-8478
Mailing Address - Fax:
Practice Address - Street 1:5650 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7140
Practice Address - Country:US
Practice Address - Phone:217-508-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002104A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical