Provider Demographics
NPI:1730493628
Name:ECKHOLT, JENNIFER J (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:J
Last Name:ECKHOLT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1223
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1223
Mailing Address - Country:US
Mailing Address - Phone:605-867-5856
Mailing Address - Fax:
Practice Address - Street 1:4500 MAIN STREET
Practice Address - Street 2:EAST HIGHWAY 18
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770
Practice Address - Country:US
Practice Address - Phone:605-867-5856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR036270163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency