MEDICARE: JESSICA FENNEWALD APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	95007322	CA

General Provider Information

NPI Number	:	1376856880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA FENNEWALD APRN

Provider Business Mailing Address
First Line	:	4005 MISSION OAKS BLVD STE A
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-484-7921
Fax Number	:	816-478-7140

Provider Business Practice Location Address
First Line	:	4005 MISSION OAKS BLVD STE A
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-484-7921
Fax Number	:	816-478-7140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2010
Last Update Date	:	01/17/2025

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