Provider Demographics
NPI:1467985390
Name:ANDERSON, JENNIFER LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S PERRY ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-1921
Mailing Address - Country:US
Mailing Address - Phone:303-688-2228
Mailing Address - Fax:
Practice Address - Street 1:1001 S PERRY ST STE 101B
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1921
Practice Address - Country:US
Practice Address - Phone:303-688-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0064820208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty