Provider Demographics
NPI:1821121625
Name:FETNER, JEAN (OT)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:FETNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 WYOMING BLVD NE
Mailing Address - Street 2:JIMMY CARTER MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5067
Mailing Address - Country:US
Mailing Address - Phone:505-292-3317
Mailing Address - Fax:505-217-0317
Practice Address - Street 1:8901 BLUEWATER RD NW
Practice Address - Street 2:JIMMY CARTER MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-2024
Practice Address - Country:US
Practice Address - Phone:505-833-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL377225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52050327Medicaid