Provider Demographics
NPI:1124001789
Name:ALLEN, JENNIFER W (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:W
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:W
Other - Last Name:BOYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1083 DONNER WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2506
Mailing Address - Country:US
Mailing Address - Phone:801-664-2722
Mailing Address - Fax:
Practice Address - Street 1:1400 FOOTHILL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2327
Practice Address - Country:US
Practice Address - Phone:801-664-2722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6738811-1205207Q00000X
IDM-11240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259C106OtherTRIWEST
AZ487406Medicaid
AZ86080015085260A076OtherTRIWEST
AZ080151322OtherRR MEDICARE
AZZ60034Medicare PIN
H06554Medicare UPIN