Provider Demographics
NPI:1720265077
Name:FURTAK, JENNY LYNN (PNP)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNN
Last Name:FURTAK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:LYNN
Other - Last Name:ETLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5666
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5606
Practice Address - Fax:314-577-5379
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000171394363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics