Provider Demographics
NPI:1649618356
Name:KIENHOLZ, JACQUELINE (PA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KIENHOLZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:BANNER MD ANDERSON CANCER CENTER
Mailing Address - Street 2:2940 E. BANNER GATEWAY DRIVE
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:BANNER MD ANDERSON CANCER CENTER
Practice Address - Street 2:2946 E. BANNER GATEWAY DRIVE
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22903363AM0700X, 364SF0001X
AZ5467363AS0400X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health