Provider Demographics
NPI:1679793012
Name:FENDO, JENNIFER ETTERS (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ETTERS
Last Name:FENDO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:ETTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:218 S MAIN ST
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3410
Mailing Address - Country:US
Mailing Address - Phone:215-616-2412
Mailing Address - Fax:
Practice Address - Street 1:218 S MAIN ST
Practice Address - Street 2:APARTMENT B
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-3410
Practice Address - Country:US
Practice Address - Phone:215-616-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003930L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist