Provider Demographics
NPI:1871945949
Name:DOHERTY, JENNIFER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:J.J.
Other - Middle Name:
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770-1201
Mailing Address - Country:US
Mailing Address - Phone:605-867-5131
Mailing Address - Fax:
Practice Address - Street 1:1 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-9998
Practice Address - Country:US
Practice Address - Phone:605-867-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-96346163W00000X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse