Provider Demographics
NPI:1083222897
Name:LONGSHORE, JENNIFER DIANE (PNP- PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:LONGSHORE
Suffix:
Gender:F
Credentials:PNP- PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4891 ECKERT ST
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-5430
Mailing Address - Country:US
Mailing Address - Phone:903-806-4166
Mailing Address - Fax:
Practice Address - Street 1:6965 TUTT BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3596
Practice Address - Country:US
Practice Address - Phone:719-266-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0995027363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics