Provider Demographics
NPI:1003369240
Name:PENCE, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PENCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4934
Mailing Address - Country:US
Mailing Address - Phone:505-841-1234
Mailing Address - Fax:
Practice Address - Street 1:735 US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3978
Practice Address - Country:US
Practice Address - Phone:719-486-0500
Practice Address - Fax:719-486-3966
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2019-0014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO531766YVBWMedicare UPIN