Provider Demographics
NPI:1841237070
Name:DERGANCE, JEANNAE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNAE
Middle Name:MARIE
Last Name:DERGANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:JEANNAE
Other - Middle Name:MARIE
Other - Last Name:COCHRAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12250 E ILIFF AVE
Mailing Address - Street 2:#300
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-6318
Mailing Address - Country:US
Mailing Address - Phone:303-306-4321
Mailing Address - Fax:720-524-1551
Practice Address - Street 1:12250 E ILIFF AVE
Practice Address - Street 2:#300
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-6318
Practice Address - Country:US
Practice Address - Phone:303-306-4321
Practice Address - Fax:720-524-1551
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44518207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15634248Medicaid
CO15634248Medicaid
COCOA104537Medicare PIN