Basic Information
| Provider Information | |||||||||
| NPI: | 1376105171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KACKLEY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5317 S TATUM LN | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852980356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807549286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1298 W FINNIE FLAT RD | ||||||||
| Address2: | |||||||||
| City: | CAMP VERDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863225958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286395555 | ||||||||
| FaxNumber: | 9286395554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2019 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 225007 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.