Provider Demographics
NPI:1588841621
Name:BLACKLER, JENNIFER RYAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RYAN
Last Name:BLACKLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RYAN
Other - Last Name:WAYMIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2001 S SHIELDS ST
Mailing Address - Street 2:BUILDING I
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1827
Mailing Address - Country:US
Mailing Address - Phone:970-221-5255
Mailing Address - Fax:970-221-5206
Practice Address - Street 1:2001 S SHIELDS ST
Practice Address - Street 2:BUILDING I
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1827
Practice Address - Country:US
Practice Address - Phone:970-221-5255
Practice Address - Fax:970-221-5206
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2546363A00000X
IDPA-795363A00000X
SD0812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807782300Medicaid
ID807782300Medicaid