Provider Demographics
NPI:1114422649
Name:PRUTER, JENNIFER R
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:PRUTER
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 1:1349 TURNER FARMS RD
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-9331
Mailing Address - Country:US
Mailing Address - Phone:209-489-5106
Mailing Address - Fax:
Practice Address - Street 1:5121 KINGDOM WAY STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6063
Practice Address - Country:US
Practice Address - Phone:800-442-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician