Provider Demographics
NPI:1083041271
Name:TETRAULT, JENNIFER WEBERS (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WEBERS
Last Name:TETRAULT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E STATE HIGHWAY 121 STE 600
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7942
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:7120 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-3926
Practice Address - Country:US
Practice Address - Phone:720-446-5891
Practice Address - Fax:303-220-9688
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant