Provider Demographics
NPI:1376856880
Name:FENNEWALD, JESSICA (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FENNEWALD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 MISSION OAKS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5156
Mailing Address - Country:US
Mailing Address - Phone:805-484-7921
Mailing Address - Fax:816-478-7140
Practice Address - Street 1:4005 MISSION OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5156
Practice Address - Country:US
Practice Address - Phone:805-484-7921
Practice Address - Fax:816-478-7140
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007322363LA2200X
TX806975363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health