Provider Demographics
NPI:1275592313
Name:FETHERSTON, JENNIFER PETERSON (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PETERSON
Last Name:FETHERSTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 N GARLAND ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-2843
Mailing Address - Country:US
Mailing Address - Phone:316-619-5345
Mailing Address - Fax:
Practice Address - Street 1:1844 N GARLAND ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2843
Practice Address - Country:US
Practice Address - Phone:316-619-5345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4851111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS510496114OtherUNITED HEALTHCARE
KS062093OtherBLUE CROSS AND BLUE SHIEL
KS510496114OtherUNITED HEALTHCARE
KS062093Medicare ID - Type Unspecified