MEDICARE: DR. JENNIFER GRACE KULL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	44144	AZ

General Provider Information

NPI Number	:	1215211776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER GRACE KULL M.D.

Provider Business Mailing Address
First Line	:	3933 E EDNA AVE
Second Line	:	102
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2127
Country	:	US
Telephone Number	:	602-569-5437
Fax Number	:	602-482-4640

Provider Business Practice Location Address
First Line	:	3933 E EDNA AVE
Second Line	:	102
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2127
Country	:	US
Telephone Number	:	602-569-5437
Fax Number	:	602-482-4640

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	10/03/2011

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