Provider Demographics
NPI:1922645696
Name:SHADE, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:SHADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:GIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1740 E BEVERLY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3564
Mailing Address - Country:US
Mailing Address - Phone:928-263-1335
Mailing Address - Fax:928-272-0173
Practice Address - Street 1:1740 E BEVERLY AVE STE B
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3564
Practice Address - Country:US
Practice Address - Phone:928-263-1335
Practice Address - Fax:928-272-0173
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN164008363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care