Provider Demographics
NPI:1043259617
Name:OTTO, JENNIFER H (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:H
Last Name:OTTO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 E RIVER RD
Mailing Address - Street 2:350
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5999
Mailing Address - Country:US
Mailing Address - Phone:520-519-7775
Mailing Address - Fax:520-519-7760
Practice Address - Street 1:1521 E TANGERINE RD
Practice Address - Street 2:STE 157
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6216
Practice Address - Country:US
Practice Address - Phone:520-229-2095
Practice Address - Fax:520-229-8501
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ582818363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ417635Medicaid
AZ417635Medicaid
Z129277Medicare PIN
AZS53495Medicare UPIN