Provider Demographics
NPI:1508913799
Name:WAARA, JENNIFER SLOCUM
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SLOCUM
Last Name:WAARA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:SLOCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1090 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3700
Mailing Address - Country:US
Mailing Address - Phone:928-583-1000
Mailing Address - Fax:866-323-8458
Practice Address - Street 1:1090 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3700
Practice Address - Country:US
Practice Address - Phone:928-583-1000
Practice Address - Fax:866-323-8458
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116859Medicare PIN