Provider Demographics
NPI:1639783160
Name:STOCKTON, JENNIFER NADINE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NADINE
Last Name:STOCKTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NADINE
Other - Last Name:IBRAHIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1 CVS DR # MC2295
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6195
Mailing Address - Country:US
Mailing Address - Phone:866-393-2727
Mailing Address - Fax:
Practice Address - Street 1:2702 W YORKSHIRE DR APT 3100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3939
Practice Address - Country:US
Practice Address - Phone:480-702-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ229088164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ491261Medicaid