Provider Demographics
NPI:1164093399
Name:GRAVENISH, JENNIFER (ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRAVENISH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 W BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 1ST ST
Practice Address - Street 2:
Practice Address - City:EMMETSBURG
Practice Address - State:IA
Practice Address - Zip Code:50536-2516
Practice Address - Country:US
Practice Address - Phone:712-221-0684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA141312163W00000X
IAG166054363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG166054OtherPSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER
IA141312OtherREGISTERED NURSE