MEDICARE: JENNIFER DOHERTY RN

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	163W00000X	Registered Nurse	NUR-RN-LIC-96346	MT
2	163WM0705X	Medical-Surgical Registered Nurse	NUR-RN-LIC-96346	MT

General Provider Information

NPI Number	:	1871945949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DOHERTY RN

Provider Business Mailing Address
First Line	:	PO BOX 1201
Second Line	:
City	:	PINE RIDGE
State	:	SD
Zip	:	57770-1201
Country	:	US
Telephone Number	:	605-867-5131
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 HIGHWAY 18
Second Line	:
City	:	PINE RIDGE
State	:	SD
Zip	:	57770-9998
Country	:	US
Telephone Number	:	605-867-5131
Fax Number	:

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

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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