Provider Demographics
NPI:1730762345
Name:DAVIDSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 N LOAFER CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-8546
Mailing Address - Country:US
Mailing Address - Phone:801-360-7316
Mailing Address - Fax:
Practice Address - Street 1:2525 S TELSHOR BLVD STE 15-202
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5071
Practice Address - Country:US
Practice Address - Phone:888-209-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCRXN.0100777-C-NP363LF0000X
NM77758363LF0000X
CA95028560363LF0000X
AZ300299363LF0000X
UT286329-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty