Provider Demographics
NPI:1356660781
Name:FENNER, MICHAEL JOHNEEL JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHNEEL
Last Name:FENNER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 NW 63RD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3606
Mailing Address - Country:US
Mailing Address - Phone:405-842-8801
Mailing Address - Fax:
Practice Address - Street 1:3035 NW 63RD ST STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-3606
Practice Address - Country:US
Practice Address - Phone:405-842-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health