Provider Demographics
NPI:1508435660
Name:FENNELL, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:FENNELL
Suffix:
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 1:170 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-9700
Mailing Address - Country:US
Mailing Address - Phone:972-400-0024
Mailing Address - Fax:
Practice Address - Street 1:170 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495-9700
Practice Address - Country:US
Practice Address - Phone:972-400-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty