Provider Demographics
NPI:1003679846
Name:SOUTH, JENASEE LORETTA
Entity Type:Individual
Prefix:
First Name:JENASEE
Middle Name:LORETTA
Last Name:SOUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 DEON LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6466
Mailing Address - Country:US
Mailing Address - Phone:208-201-2256
Mailing Address - Fax:
Practice Address - Street 1:14961 W BELL RD STE 175
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3220
Practice Address - Country:US
Practice Address - Phone:623-547-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife