Provider Demographics
NPI:1487125076
Name:FAST WOLF, JENNIFER MICHELLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:FAST WOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 E 960 S APT S102
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3396
Mailing Address - Country:US
Mailing Address - Phone:435-219-2656
Mailing Address - Fax:
Practice Address - Street 1:111 S SECOND ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6219
Practice Address - Country:US
Practice Address - Phone:505-409-0726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-08
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor