1548262066 NPI number — JENNIFER MARIE BETTENHAUSEN MD

Table of content: JENNIFER MARIE BETTENHAUSEN MD (NPI 1548262066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548262066 NPI number — JENNIFER MARIE BETTENHAUSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTENHAUSEN
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHILLIPS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548262066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1749
Provider Second Line Business Mailing Address:
C/O CREDENTIALING-LISA KERSTIENS
Provider Business Mailing Address City Name:
EDWARDS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81632-1749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-926-6340
Provider Business Mailing Address Fax Number:
970-926-6348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
377 SYLVAN LAKE RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-328-1650
Provider Business Practice Location Address Fax Number:
970-328-1651
Provider Enumeration Date:
08/15/2005

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: 207Q00000X , with the licence number:  34815 , 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: 01348150 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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