Provider Demographics
NPI:1790147874
Name:FERNANDEZ, JENELLE (MD)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6450
Mailing Address - Country:US
Mailing Address - Phone:866-401-3057
Mailing Address - Fax:308-868-6430
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1541
Practice Address - Country:US
Practice Address - Phone:251-410-5437
Practice Address - Fax:251-434-3851
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1393452080P0206X
ALMD.483242080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4HYBAOtherBLUE CROSS BLUE SHIELD
FL114879000Medicaid