Provider Demographics
NPI:1881963437
Name:FENNELL, JENNIFER E (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:E
Last Name:FENNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 SOUTH BERKELEY LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071
Mailing Address - Country:US
Mailing Address - Phone:770-446-5642
Mailing Address - Fax:770-446-5643
Practice Address - Street 1:4530 SOUTH BERKELEY LAKE ROAD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071
Practice Address - Country:US
Practice Address - Phone:770-446-5642
Practice Address - Fax:770-446-5643
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical