Provider Demographics
NPI:1417022559
Name:HALL, JENNIFER ELIZABETH (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:HALL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:HERMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86002-0967
Mailing Address - Country:US
Mailing Address - Phone:928-773-0003
Mailing Address - Fax:928-773-1170
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-773-0003
Practice Address - Fax:928-773-1170
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201668207R00000X
IDOC-0401207RC0200X
AZ007219207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ259746Medicaid