Provider Demographics
NPI:1679025605
Name:PROVIDENCE, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PROVIDENCE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3349 E PRESIDIO RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1633
Mailing Address - Country:US
Mailing Address - Phone:520-332-5509
Mailing Address - Fax:
Practice Address - Street 1:300 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-6130
Practice Address - Country:US
Practice Address - Phone:520-332-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1046171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist