Basic Information
Provider Information | |||||||||
NPI: | 1992916811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAKER | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LANDRY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAKER | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 173891 | ||||||||
Address2: | DEPARTMENT OF EMERGENCY MEDICINE | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802173891 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033067101 | ||||||||
FaxNumber: | 3033067753 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E BOULDER ST | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809095533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7193655000 | ||||||||
FaxNumber: | 3033067753 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 07/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD201374 | LA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | M9828 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | DR.0052241 | CO | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 37525581 | 05 | CO |   | MEDICAID |