Healthcare Provider Details

I. General information

NPI: 1912769944
Provider Name (Legal Business Name): JENNIFER SOLOMON AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1944 MESQUITE AVE
LAKE HAVASU CITY AZ
86403-5729
US

IV. Provider business mailing address

1600 MCCULLOCH BLVD N STE 3A
LAKE HAVASU CITY AZ
86403-0959
US

V. Phone/Fax

Practice location:
  • Phone: 928-405-0079
  • Fax:
Mailing address:
  • Phone: 928-486-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number239721
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number239721
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: