Provider Demographics
NPI:1104934033
Name:FERGON, JOLYN (NP, CNM)
Entity type:Individual
Prefix:
First Name:JOLYN
Middle Name:
Last Name:FERGON
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N PALM CANYON DR STE 212
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4426
Mailing Address - Country:US
Mailing Address - Phone:760-327-7900
Mailing Address - Fax:760-327-7905
Practice Address - Street 1:1100 N PALM CANYON DR STE 212
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4426
Practice Address - Country:US
Practice Address - Phone:760-327-7900
Practice Address - Fax:760-327-7905
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10593363LX0001X
CA1727367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101241Medicaid
CAZZZ27958ZOtherMEDICARE GROUP ID
CAGR0101242Medicaid
CAGR0101240Medicaid