Provider Demographics
NPI:1083712327
Name:FLYNN, JODI (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:FLYNN
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 1:582 PARK PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2689
Mailing Address - Country:US
Mailing Address - Phone:417-299-2905
Mailing Address - Fax:970-230-6438
Practice Address - Street 1:589 S STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5056
Practice Address - Country:US
Practice Address - Phone:801-602-4795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002309363AM0700X
UT13724198-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP82212Medicare UPIN
MO97249Medicare ID - Type Unspecified