Provider Demographics
NPI:1083798532
Name:FENGER, JESSE T (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:T
Last Name:FENGER
Suffix:
Gender:M
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 1:2512 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3399
Mailing Address - Country:US
Mailing Address - Phone:360-782-3650
Mailing Address - Fax:360-782-3686
Practice Address - Street 1:19245 7TH AVE NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6651
Practice Address - Country:US
Practice Address - Phone:360-782-3500
Practice Address - Fax:360-782-3540
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
227800000X
AK728363A00000X
WAPA-10005297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified