Provider Demographics
NPI:1679782791
Name:JENNINGS, FREDERICK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-624-4443
Mailing Address - Fax:970-490-4175
Practice Address - Street 1:525 N FOOTE AVE
Practice Address - Street 2:STE 302
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4501
Practice Address - Country:US
Practice Address - Phone:719-365-5445
Practice Address - Fax:719-365-5530
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1908363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86376365Medicaid
CO86376365Medicaid
COC0A109637Medicare PIN
COP58510Medicare UPIN