Basic Information
| Provider Information | |||||||||
| NPI: | 1508274028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805385006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708103894 | ||||||||
| FaxNumber: | 9708103897 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805385006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708103894 | ||||||||
| FaxNumber: | 9708103897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3998 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 3998 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MS3247928 | 01 | CO | DEAX | OTHER |