Provider Demographics
NPI:1316069727
Name:DE GRAAUW, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DE GRAAUW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4891 INDEPENDENCE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6713
Mailing Address - Country:US
Mailing Address - Phone:303-456-5495
Mailing Address - Fax:303-456-7490
Practice Address - Street 1:8100 CONSTITUTION PL NE STE 400
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7644
Practice Address - Country:US
Practice Address - Phone:505-559-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48168207RN0300X
NMMD2014-0937207RN0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22625771Medicaid
COCO306966Medicare PIN
CO020592OtherKAISER COMMERCIAL NUMBER