Provider Demographics
NPI:1962423582
Name:FENNEL, H JACK (OD)
Entity type:Individual
Prefix:DR
First Name:H
Middle Name:JACK
Last Name:FENNEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080
Mailing Address - Country:US
Mailing Address - Phone:530-527-2211
Mailing Address - Fax:530-527-7412
Practice Address - Street 1:1031 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080
Practice Address - Country:US
Practice Address - Phone:530-527-2211
Practice Address - Fax:530-527-7412
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5114T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051140Medicaid
CASD0051140Medicare ID - Type Unspecified
CA0675830001Medicare NSC
T09874Medicare UPIN