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General NPI Number Information
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NPI Number | 1376462655
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Entity Type | Individual
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Provider Name | MERCEDES JADE PENNEBAKER
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Gender | Female
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Dates
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Enumeration Date | 07/13/2026
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Last Update Date | 07/13/2026
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Provider Practice Location Address
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Address Line | 540 S COLLEGE AVE STE 160
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City | NEWARK
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State | DE
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Zip | 19713-1302
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Country | US
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Telephone | 302-831-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 1905 215TH LN NW
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City | OAK GROVE
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State | MN
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Zip | 55011-9196
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Country | US
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Telephone | 763-438-3119
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | J1-0015205
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | J1-0015205
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License Number State | DE
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