Provider Demographics
NPI:1235420993
Name:DAVIS, JENNIFER LYN (LPN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:AZ
Mailing Address - Zip Code:85534-0005
Mailing Address - Country:US
Mailing Address - Phone:928-792-6179
Mailing Address - Fax:
Practice Address - Street 1:1300 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-792-6179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP041267164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse