Provider Demographics
NPI:1730787383
Name:FORTNER, JENNIFER ROSE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-0246
Mailing Address - Country:US
Mailing Address - Phone:304-362-1915
Mailing Address - Fax:
Practice Address - Street 1:481 VALLEY DR
Practice Address - Street 2:
Practice Address - City:OCEANA
Practice Address - State:WV
Practice Address - Zip Code:24870-7819
Practice Address - Country:US
Practice Address - Phone:304-362-1915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant