Provider Demographics
NPI:1497086912
Name:PEDERSEN, JENNIFER (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E MISSOURI AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8917
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:1850 N CENTRAL AVE STE 1600
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275352163W00000X, 367500000X
AZCRNA1062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ171905Medicare PIN