Provider Demographics
NPI:1457713588
Name:GOULD, JENNIFER ANN
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:GOULD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:WELTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:907 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-3027
Mailing Address - Country:US
Mailing Address - Phone:480-823-2020
Mailing Address - Fax:
Practice Address - Street 1:907 RYAN STREET
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:480-823-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF696052471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography