Provider Demographics
NPI:1821317132
Name:SCHULTEN, JENNA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNA
Middle Name:R
Last Name:SCHULTEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 DELOR AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2226
Mailing Address - Country:US
Mailing Address - Phone:270-789-7890
Mailing Address - Fax:
Practice Address - Street 1:1001 N DUPONT SQ
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4612
Practice Address - Country:US
Practice Address - Phone:270-789-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY88681223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100151020Medicaid