Provider Demographics
NPI:1386020659
Name:EDDY, JELENA (PA)
Entity Type:Individual
Prefix:
First Name:JELENA
Middle Name:
Last Name:EDDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9348 GRAND CORDERA PKWY STE 160
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-7023
Mailing Address - Country:US
Mailing Address - Phone:719-355-1585
Mailing Address - Fax:719-623-2983
Practice Address - Street 1:9348 GRAND CORDERA PKWY STE 160
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-7023
Practice Address - Country:US
Practice Address - Phone:719-355-1585
Practice Address - Fax:719-623-2983
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant