Provider Demographics
NPI:1083898712
Name:CHITTUM, JENNIFER ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:CHITTUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-3993
Mailing Address - Country:US
Mailing Address - Phone:505-425-3566
Mailing Address - Fax:
Practice Address - Street 1:501 7TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3993
Practice Address - Country:US
Practice Address - Phone:505-425-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2009-0114208000000X
TXN3561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics