Healthcare Provider Details

I. General information

NPI: 1164561569
Provider Name (Legal Business Name): JEFF GORDON FENTON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 E 27TH AVE
SPOKANE WA
99223-4908
US

IV. Provider business mailing address

2507 E 27TH AVE
SPOKANE WA
99223-4908
US

V. Phone/Fax

Practice location:
  • Phone: 509-456-6917
  • Fax: 509-456-5902
Mailing address:
  • Phone: 509-456-6917
  • Fax: 509-456-5902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5460
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: