Healthcare Provider Details

I. General information

NPI: 1376462655
Provider Name (Legal Business Name): MERCEDES JADE PENNEBAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SADIE JADE PENNEBAKER

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 S COLLEGE AVE STE 160
NEWARK DE
19713-1302
US

IV. Provider business mailing address

1905 215TH LN NW
OAK GROVE MN
55011-9196
US

V. Phone/Fax

Practice location:
  • Phone: 302-831-3000
  • Fax:
Mailing address:
  • Phone: 763-438-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0015205
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ1-0015205
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: