Provider Demographics
NPI:1760733083
Name:CHAVEZ, JESSICA JOVANA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOVANA
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:J
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:303-695-2628
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0159521363A00000X
CO0003977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01401645OtherRAILROAD MEDICARE
CO59124377Medicaid
CO59124377Medicaid