Provider Demographics
NPI:1376163790
Name:PENNER, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:PENNER
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:PSC 1005
Mailing Address - Street 2:BOX 11219
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34009
Mailing Address - Country:CU
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 1005
Practice Address - Street 2:BOX 11219
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34009
Practice Address - Country:CU
Practice Address - Phone:757-458-2944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101276005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine