Healthcare Provider Details

I. General information

NPI: 1043682669
Provider Name (Legal Business Name): JENNA RENFROE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENA DIETZ PHD

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-2156
US

IV. Provider business mailing address

717 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-2156
US

V. Phone/Fax

Practice location:
  • Phone: 336-542-1800
  • Fax: 336-542-1800
Mailing address:
  • Phone: 336-542-1800
  • Fax: 336-542-1800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY9563
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: