Provider Demographics
NPI:1972973733
Name:KRUG, JENNIFER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KRUG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 N WILMOT RD # 121
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4410
Mailing Address - Country:US
Mailing Address - Phone:520-222-8061
Mailing Address - Fax:
Practice Address - Street 1:5151 E BROADWAY BLVD
Practice Address - Street 2:STE 1600
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3777
Practice Address - Country:US
Practice Address - Phone:520-222-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 27663103T00000X
AZPSY-005113103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist