Provider Demographics
NPI:1336406867
Name:DOLPH, JAYLENE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:JAYLENE
Middle Name:MARIE
Last Name:DOLPH
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 1:1431 93RD ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-9633
Mailing Address - Country:US
Mailing Address - Phone:715-323-2532
Mailing Address - Fax:
Practice Address - Street 1:1431 93RD ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-9633
Practice Address - Country:US
Practice Address - Phone:715-323-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-22
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315300164W00000X
WI193606163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse