Healthcare Provider Details

I. General information

NPI: 1730762345
Provider Name (Legal Business Name): JENNIFER DAVIDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S TELSHOR BLVD STE 15-202
LAS CRUCES NM
88011-5071
US

IV. Provider business mailing address

87 N LOAFER CANYON RD
ELK RIDGE UT
84651-8546
US

V. Phone/Fax

Practice location:
  • Phone: 888-209-8874
  • Fax:
Mailing address:
  • Phone: 801-360-7316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCRXN.0100777-C-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number300299
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number286329-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028560
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77758
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: