Provider Demographics
NPI:1194121657
Name:ABRAHAM, JENNIFER V (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:V
Last Name:ABRAHAM
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 1:3433 WARREN FARM DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6344
Mailing Address - Country:US
Mailing Address - Phone:651-319-1563
Mailing Address - Fax:
Practice Address - Street 1:3433 WARREN FARM DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6344
Practice Address - Country:US
Practice Address - Phone:651-319-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004068363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10237259Medicaid