Provider Demographics
NPI:1558400051
Name:HARGROVE, JENNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:HARGROVE
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:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-609-2000
Practice Address - Fax:505-609-2259
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87959207P00000X
CO45957207P00000X
NMMD2009-0130207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A879590OtherMEDI-CAL PROVIDER NUMBER
CO78401054Medicaid
CAI29755Medicare UPIN
COC303583Medicare PIN
CO78401054Medicaid