Provider Demographics
NPI:1912410028
Name:FENNEY, JORDAN LYN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LYN
Last Name:FENNEY
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 1:4907 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9255
Mailing Address - Country:US
Mailing Address - Phone:262-224-5151
Mailing Address - Fax:
Practice Address - Street 1:4907 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9255
Practice Address - Country:US
Practice Address - Phone:262-224-5151
Practice Address - Fax:262-224-5151
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer