Provider Demographics
NPI:1477184273
Name:GAVIDIA JARA, JEANS PRISCILLA (NA00764606)
Entity type:Individual
Prefix:
First Name:JEANS
Middle Name:PRISCILLA
Last Name:GAVIDIA JARA
Suffix:
Gender:F
Credentials:NA00764606
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9039 E GIRARD AVE # 48
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-5007
Mailing Address - Country:US
Mailing Address - Phone:720-207-4208
Mailing Address - Fax:
Practice Address - Street 1:9039 E GIRARD AVE # 48
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-5007
Practice Address - Country:US
Practice Address - Phone:720-207-4208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00764606376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty