Healthcare Provider Details

I. General information

NPI: 1609012368
Provider Name (Legal Business Name): JENNIFER H FORTENBERRY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER HANSHAW MCGOVERN

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 PARK DR STE 101
HARRISBURG PA
17110-9303
US

IV. Provider business mailing address

3421 CONCORD RD
YORK PA
17402-9001
US

V. Phone/Fax

Practice location:
  • Phone: 717-686-9842
  • Fax:
Mailing address:
  • Phone: 717-851-1405
  • Fax: 717-851-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2002014284
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number2002014284
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056018
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: