Provider Demographics
NPI:1932265089
Name:COULTER, JENNIFER BROOKE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BROOKE
Last Name:COULTER
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 1:2018 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6414
Mailing Address - Country:US
Mailing Address - Phone:541-850-1358
Mailing Address - Fax:
Practice Address - Street 1:2018 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6414
Practice Address - Country:US
Practice Address - Phone:541-850-1358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098240Medicaid
OR098240Medicaid