Provider Demographics
NPI:1538327143
Name:WALL, JENNIFER LYN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:WALL
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 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-632-7837
Practice Address - Street 1:155 PRINTERS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-6100
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics