Provider Demographics
NPI:1649364498
Name:BRENTON, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:BRENTON
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 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:19 FRIENDSHIP ST UNIT 220
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2264
Practice Address - Country:US
Practice Address - Phone:401-848-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14808207V00000X, 207V00000X
WI47199020207V00000X
IL036141686208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32882800Medicaid
WI34580800Medicaid
WIH56820Medicare UPIN
WI32882800Medicaid
WI34580800Medicaid