Provider Demographics
NPI:1679555023
Name:PENTECOST, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PENTECOST
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 1:2001 EL CENTRO FAMILIAR BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4592
Mailing Address - Country:US
Mailing Address - Phone:505-768-5450
Mailing Address - Fax:505-842-1185
Practice Address - Street 1:1401 WILLIAM ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4661
Practice Address - Country:US
Practice Address - Phone:505-768-5450
Practice Address - Fax:505-842-1185
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM20023084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F70580Medicare UPIN
NM01330141Medicare ID - Type Unspecified