Provider Demographics
NPI:1134668189
Name:FENSTER, JACOB ROBERT
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:FENSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-277-3960
Practice Address - Street 1:5001 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1308
Practice Address - Country:US
Practice Address - Phone:601-296-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSWILL APPLY207P00000X
IL036156624207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine