Provider Demographics
NPI:1376105171
Name:DORN, JENNIFER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DORN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5317 S TATUM LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-0356
Mailing Address - Country:US
Mailing Address - Phone:480-754-9286
Mailing Address - Fax:
Practice Address - Street 1:1298 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-5958
Practice Address - Country:US
Practice Address - Phone:928-639-5555
Practice Address - Fax:928-639-5554
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily