Provider Demographics
NPI:1811372543
Name:FENN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W BROADWAY ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-6205
Mailing Address - Country:US
Mailing Address - Phone:580-226-5209
Mailing Address - Fax:580-226-5219
Practice Address - Street 1:115 W BROADWAY ST
Practice Address - Street 2:SUITE 401
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6205
Practice Address - Country:US
Practice Address - Phone:580-226-5209
Practice Address - Fax:580-226-5219
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker