Provider Demographics
NPI:1912057639
Name:FENNER, JOHN CLARE (MSSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARE
Last Name:FENNER
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 S CAPITAL OF TEXAS HWY
Mailing Address - Street 2:#A-200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7762
Mailing Address - Country:US
Mailing Address - Phone:512-327-0020
Mailing Address - Fax:512-327-0030
Practice Address - Street 1:2499 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:#A-200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-7762
Practice Address - Country:US
Practice Address - Phone:512-327-0020
Practice Address - Fax:512-327-0030
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F5770Medicare PIN