Healthcare Provider Details

I. General information

NPI: 1841164266
Provider Name (Legal Business Name): JENNIFER DIANE BURNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER DIANE LOPEZ

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CANYON RD
BULLHEAD CITY AZ
86442-8624
US

IV. Provider business mailing address

2500 CANYON RD STE A1
BULLHEAD CITY AZ
86442-8492
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-4499
  • Fax: 928-704-4949
Mailing address:
  • Phone: 928-704-4499
  • Fax: 928-704-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number331686
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: