Healthcare Provider Details

I. General information

NPI: 1356300271
Provider Name (Legal Business Name): JACK FENNEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 MISSOURI AVE
FORT LEONARD WOOD MO
65473-8952
US

IV. Provider business mailing address

126 MISSOURI AVE
FORT LEONARD WOOD MO
65473-8952
US

V. Phone/Fax

Practice location:
  • Phone: 573-329-8305
  • Fax: 573-329-8302
Mailing address:
  • Phone: 573-329-8305
  • Fax: 573-329-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9D28
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberR9D28
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: