Basic Information
| Provider Information | |||||||||
| NPI: | 1043280043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOELK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEVY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAINES | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LEVY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 43661 | CO | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 43661 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00425164 | 01 | CO | RAILROAD MEDICARE | OTHER | 90236831 | 05 | CO | MEDICAID |