Provider Demographics
NPI:1124572888
Name:POULSON, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:POULSON
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 1:1000 E MESQUITE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1814
Mailing Address - Country:US
Mailing Address - Phone:480-813-1240
Mailing Address - Fax:
Practice Address - Street 1:1000 E MESQUITE ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1814
Practice Address - Country:US
Practice Address - Phone:480-813-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN168866163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse