Provider Demographics
NPI:1497968101
Name:PENNE, JENNIFER JOHANNA (APN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOHANNA
Last Name:PENNE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2566 E JOYCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4553
Mailing Address - Country:US
Mailing Address - Phone:479-935-1000
Mailing Address - Fax:479-935-2000
Practice Address - Street 1:2566 E JOYCE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4553
Practice Address - Country:US
Practice Address - Phone:479-935-1000
Practice Address - Fax:479-935-2000
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR 72401163W00000X
MO2021008266363LP0808X
ARA003632363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR193306758Medicaid
MO420094195Medicaid