Provider Demographics
NPI:1124600267
Name:FOFANAH, JENEBA
Entity Type:Individual
Prefix:
First Name:JENEBA
Middle Name:
Last Name:FOFANAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENEBA
Other - Middle Name:
Other - Last Name:ENOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JENEBA ENOW
Mailing Address - Street 1:2235 DAWN SHADOW WAY
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8753
Mailing Address - Country:US
Mailing Address - Phone:832-230-9329
Mailing Address - Fax:
Practice Address - Street 1:2235 DAWN SHADOW WAY
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8753
Practice Address - Country:US
Practice Address - Phone:832-230-9329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherN/A