Active NPI
Jack Sutton Fenner
- Athletic Trainer
- Shreveport, LA
National Provider Identifier
1205629672
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- 012122580
- Practice address
- 427 Prestonwood Dr
Shreveport, LA 71115-3723 - Phone
- (318) 344-3686
- NPI assigned
- May 27, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 012122580 | LA | Primary |
Addresses
Primary practice location
427 Prestonwood Dr
Shreveport, LA 71115-3723
Mailing address
427 Prestonwood Dr
Shreveport, LA 71115-3723
Phone (318) 344-3686
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 012122580 | LA | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1748304000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1748304000000",
"number": "1205629672",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "427 PRESTONWOOD DR",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711153723",
"telephone_number": "318-344-3686"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "427 PRESTONWOOD DR",
"city": "SHREVEPORT",
"state": "LA",
"postal_code": "711153723",
"telephone_number": "318-344-3686"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FENNER",
"first_name": "JACK",
"middle_name": "SUTTON",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-05-27",
"last_updated": "2025-05-27",
"certification_date": "2025-05-27",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "LA",
"license": "012122580",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Shreveport, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.