Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | APN.0992162-NP | CO |
NPI | 1003368150 |
---|---|
Provider Name | Jennifer Mack |
First Address | Highlands Ranch, CO 80129-5690 |
Second Address | Littleton, CO 80123-3093 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2016 |
Last Update Date | 25/10/2016 |