Provider Demographics
NPI:1225678261
Name:VAIL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VAIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CASTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 E ROUTT AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2117
Mailing Address - Country:US
Mailing Address - Phone:719-543-8711
Mailing Address - Fax:719-585-3057
Practice Address - Street 1:300 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2006
Practice Address - Country:US
Practice Address - Phone:719-543-8178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995263-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife