Provider Demographics
NPI:1831425032
Name:PENNER, JESSICA LEIGH (RN)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:LEIGH
Last Name:PENNER
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 1:23 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-5094
Mailing Address - Country:US
Mailing Address - Phone:928-778-2734
Mailing Address - Fax:
Practice Address - Street 1:23 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-5094
Practice Address - Country:US
Practice Address - Phone:928-778-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN158856163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse