Provider Demographics
NPI:1215211776
Name:KULL, JENNIFER GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:GRACE
Last Name:KULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 E EDNA AVE
Mailing Address - Street 2:102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2127
Mailing Address - Country:US
Mailing Address - Phone:602-569-5437
Mailing Address - Fax:602-482-4640
Practice Address - Street 1:3933 E EDNA AVE
Practice Address - Street 2:102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2127
Practice Address - Country:US
Practice Address - Phone:602-569-5437
Practice Address - Fax:602-482-4640
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44144174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist