Basic Information
Provider Information
NPI: 1003001256
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARAGOL
FirstName: JENNIFER
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2930 11TH AVE
Address2:  
City: EVANS
State: CO
PostalCode: 806201011
CountryCode: US
TelephoneNumber: 9703539403
FaxNumber: 9703539906
Practice Location
Address1: 2930 11TH AVE
Address2:  
City: EVANS
State: CO
PostalCode: 806201011
CountryCode: US
TelephoneNumber: 9703539403
FaxNumber: 9703539906
Other Information
ProviderEnumerationDate: 09/11/2007
LastUpdateDate: 09/11/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X44132COY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
1953527905CO MEDICAID


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