Provider Demographics
NPI:1679009823
Name:PRINCE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PRINCE
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 1:35 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:KOTLIK
Mailing Address - State:AK
Mailing Address - Zip Code:99620
Mailing Address - Country:US
Mailing Address - Phone:907-899-4511
Mailing Address - Fax:907-899-4414
Practice Address - Street 1:35 MAIN STREET
Practice Address - Street 2:
Practice Address - City:KOTLIK
Practice Address - State:AK
Practice Address - Zip Code:99620
Practice Address - Country:US
Practice Address - Phone:907-899-4511
Practice Address - Fax:907-899-4414
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker