Provider Demographics
NPI:1265749147
Name:DEFORD, JENNIFER RAE (RN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RAE
Last Name:DEFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USAG-J UNIT 45013
Mailing Address - Street 2:BOX 3315
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USAG-J UNIT 45013
Practice Address - Street 2:BOX 3315
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96338
Practice Address - Country:US
Practice Address - Phone:0118146-407-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1111514163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse