Provider Demographics
NPI:1710282561
Name:ROBERTS, JENNIFER RAE (CNM)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:RAE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 560825
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0825
Mailing Address - Country:US
Mailing Address - Phone:719-595-7580
Mailing Address - Fax:719-545-0176
Practice Address - Street 1:4010 JERRY MURPHY RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1045
Practice Address - Country:US
Practice Address - Phone:719-546-2229
Practice Address - Fax:719-583-9069
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
COCNM170007367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO27020258Medicaid
CO505641YK2DMedicare PIN