Provider Demographics
NPI:1184624520
Name:SIMONSON, JENNIFER S (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:S
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 KANEMOTO LN
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-6946
Mailing Address - Country:US
Mailing Address - Phone:720-281-5042
Mailing Address - Fax:303-443-4599
Practice Address - Street 1:1790 30TH ST STE 311
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1020
Practice Address - Country:US
Practice Address - Phone:303-443-2257
Practice Address - Fax:303-443-4599
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2393152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62757008Medicaid
COU98001Medicare UPIN
CO62757008Medicaid