Provider Demographics
NPI:1164561569
Name:FENTON, JEFF GORDON (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:GORDON
Last Name:FENTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 E 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4908
Mailing Address - Country:US
Mailing Address - Phone:509-456-6917
Mailing Address - Fax:509-456-5902
Practice Address - Street 1:2507 E 27TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4908
Practice Address - Country:US
Practice Address - Phone:509-456-6917
Practice Address - Fax:509-456-5902
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5460208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8332652Medicaid
WA8332652Medicaid