Provider Demographics
NPI:1942716600
Name:WILLIS, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10895 DAYTON WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10895 DAYTON WAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:CO
Practice Address - Zip Code:80640-7549
Practice Address - Country:US
Practice Address - Phone:720-376-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical