Provider Demographics
NPI:1063256253
Name:KENT-MARVICK, JACQUELINE MARIE (PHD, RN)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:KENT-MARVICK
Suffix:
Gender:F
Credentials:PHD, RN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2246 S CHEKSHANI CLF
Mailing Address - Street 2:
Mailing Address - City:NEW HARMONY
Mailing Address - State:UT
Mailing Address - Zip Code:84757-5133
Mailing Address - Country:US
Mailing Address - Phone:435-668-6932
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:435-668-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4904131-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4904131-3102OtherLICENSE NUMBER