Provider Demographics
NPI:1093046625
Name:CAPPELLO, JENNA BRIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:BRIANNE
Last Name:CAPPELLO
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 1:1551 PROFESSIONAL LN
Mailing Address - Street 2:STE. 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6972
Mailing Address - Country:US
Mailing Address - Phone:303-772-1600
Mailing Address - Fax:303-772-9317
Practice Address - Street 1:1551 PROFESSIONAL LN
Practice Address - Street 2:STE. 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6972
Practice Address - Country:US
Practice Address - Phone:303-772-1600
Practice Address - Fax:303-772-9317
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant