Provider Demographics
NPI:1497063671
Name:FARDINK, JENNIFER R (LM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:FARDINK
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 TINY TOWN RD # 252
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-7202
Mailing Address - Country:US
Mailing Address - Phone:928-919-4566
Mailing Address - Fax:
Practice Address - Street 1:1477 TINY TOWN RD # 252
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7202
Practice Address - Country:US
Practice Address - Phone:928-919-4566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99102176B00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife