Provider Demographics
NPI:1992871495
Name:FENNERTY, JACQUELINE MARIA (DPM)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIA
Last Name:FENNERTY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:MARIA
Other - Last Name:KORDICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:25121 TRIPP RD
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:OR
Mailing Address - Zip Code:97437-9612
Mailing Address - Country:US
Mailing Address - Phone:415-219-3875
Mailing Address - Fax:541-302-9481
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-735-9420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00292213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150584Medicaid
ORR100472Medicare PIN
OR150584Medicaid
OR4540570001Medicare NSC