Provider Demographics
NPI:1285945550
Name:RENAKER, JESSICA HANCOCK (DMD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:HANCOCK
Last Name:RENAKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2412
Mailing Address - Country:US
Mailing Address - Phone:812-479-5000
Mailing Address - Fax:
Practice Address - Street 1:508 N GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2412
Practice Address - Country:US
Practice Address - Phone:812-479-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011438A1223G0001X
KY88901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice