Basic Information
| Provider Information | |||||||||
| NPI: | 1609012368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTENBERRY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGOVERN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | HANSHAW | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 PARK DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171109303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176869842 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2008 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2002014284 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207XX0004X | 2002014284 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 363AM0700X | MA056018 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1620177 | 01 | PA | GATEWAY MEDICARE ASSURED | OTHER | 2888522 | 01 | PA | HIGHMARK BLUE SHIELD-FREEDOM BLUE | OTHER |