Provider Demographics
NPI:1861724916
Name:FENNER, JEANNE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:ELIZABETH
Last Name:FENNER
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 1:47 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5312
Mailing Address - Country:US
Mailing Address - Phone:718-857-6459
Mailing Address - Fax:
Practice Address - Street 1:30 MARTENSE ST
Practice Address - Street 2:#LA
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3273
Practice Address - Country:US
Practice Address - Phone:718-857-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-30
Last Update Date:2010-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096127208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics