Provider Demographics
NPI:1609012368
Name:FORTENBERRY, JENNIFER H (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:H
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:HANSHAW
Other - Last Name:MCGOVERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-6969
Practice Address - Street 1:2401 PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9303
Practice Address - Country:US
Practice Address - Phone:717-686-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014284363AS0400X, 207XX0004X
PAMA056018363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1620177OtherGATEWAY MEDICARE ASSURED
PA2888522OtherHIGHMARK BLUE SHIELD-FREEDOM BLUE
PA2888522OtherHIGHMARK BLUE SHIELD-FREEDOM BLUE
PA279298FLTMedicare PIN
MO122950055Medicare PIN