Provider Demographics
NPI:1780294793
Name:KING, JENNIFER LAKE (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAKE
Last Name:KING
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 S JOSHUA AVE
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-5057
Mailing Address - Country:US
Mailing Address - Phone:928-669-9700
Mailing Address - Fax:928-669-9104
Practice Address - Street 1:1016 S JOSHUA AVE
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5057
Practice Address - Country:US
Practice Address - Phone:928-669-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ245759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily