Provider Demographics
NPI:1720551732
Name:LANDRUM, JENNIFER MARTINA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARTINA
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:FNP-BC
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 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:601 W RIVERSIDE DR STE 2
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:928-256-4110
Practice Address - Fax:928-256-4112
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF10181025363LF0000X
AZ240917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily