Provider Demographics
NPI:1679538748
Name:VON KOLEN, JENNIFER (MS/ ATC/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:VON KOLEN
Suffix:
Gender:F
Credentials:MS/ ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 W ALAMEDA RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-3704
Mailing Address - Country:US
Mailing Address - Phone:623-587-9368
Mailing Address - Fax:
Practice Address - Street 1:5343 W ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-3704
Practice Address - Country:US
Practice Address - Phone:623-445-5377
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0379OtherATHLETIC TRAINER LISC. #