Provider Demographics
NPI:1770834483
Name:MARSHALL, JENNIE MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:MARIE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:MARIE
Other - Last Name:KNOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1633 S EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-6529
Mailing Address - Country:US
Mailing Address - Phone:720-261-3300
Mailing Address - Fax:
Practice Address - Street 1:1633 S EVERETT ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-6529
Practice Address - Country:US
Practice Address - Phone:720-261-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0165688163W00000X
COAPN0990465363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51139308Medicaid
COAPN 0990465OtherSTATE OF COLORADO
COAPN 0990465OtherSTATE OF COLORADO