Provider Demographics
NPI:1255488557
Name:DUMBOLTON, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DUMBOLTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5574
Mailing Address - Country:US
Mailing Address - Phone:928-474-2888
Mailing Address - Fax:928-474-2992
Practice Address - Street 1:122 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5574
Practice Address - Country:US
Practice Address - Phone:928-474-2888
Practice Address - Fax:928-474-2992
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-7684207Q00000X
AZ005119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ386378Medicaid
IA0476960Medicaid
IA0476960Medicaid