Provider Demographics
NPI:1770127730
Name:FENWCK, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:FENWCK
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 1:13204 VANESSA AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4748
Mailing Address - Country:US
Mailing Address - Phone:240-893-9728
Mailing Address - Fax:
Practice Address - Street 1:15480 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1852
Practice Address - Country:US
Practice Address - Phone:240-893-9728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4510261744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD451026OtherPROSTHETIC SPECIALIST