1023386919 NPI number — JENNIFER L VAN HORN AOCNS

Table of content: JENNIFER L VAN HORN AOCNS (NPI 1023386919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023386919 NPI number — JENNIFER L VAN HORN AOCNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN HORN
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AOCNS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023386919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-463-5000
Provider Business Mailing Address Fax Number:
208-375-2217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 BOISE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVELAND
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-820-4351
Provider Business Practice Location Address Fax Number:
970-810-3897
Provider Enumeration Date:
12/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SX0200X , with the licence number:  29968.1138 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: APN.0995749-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1023386919 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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