Provider Demographics
NPI:1467425751
Name:OTTERBEIN, JENNIFER L (RN, CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:OTTERBEIN
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CNP
Mailing Address - Street 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5452
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2375363L00000X
MNCNP2375363LA2200X
AZ248715363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN804650600Medicaid
Q28302Medicare UPIN
MNP00237069Medicare ID - Type UnspecifiedRAILROAD
MN804650600Medicaid