Provider Demographics
NPI:1063793289
Name:DERAAD, JENNIFER E (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:DERAAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 E STUART ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1195
Mailing Address - Country:US
Mailing Address - Phone:970-829-1129
Mailing Address - Fax:
Practice Address - Street 1:1136 E STUART ST STE 202
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1195
Practice Address - Country:US
Practice Address - Phone:970-829-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-01
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12614-NP363LF0000X
COAPN0995434363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily