Provider Demographics
NPI:1639474158
Name:DEMARCE, JENNIE R
Entity Type:Individual
Prefix:MISS
First Name:JENNIE
Middle Name:R
Last Name:DEMARCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2094
Mailing Address - Street 2:
Mailing Address - City:MILLS
Mailing Address - State:WY
Mailing Address - Zip Code:82644-2094
Mailing Address - Country:US
Mailing Address - Phone:307-472-5090
Mailing Address - Fax:
Practice Address - Street 1:123 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-1703
Practice Address - Country:US
Practice Address - Phone:307-472-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY104647342251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services