MEDICARE: MS. JENNIFER NELL KOOS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	499431	CA

General Provider Information

NPI Number	:	1235406638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER NELL KOOS NP

Provider Business Mailing Address
First Line	:	1152 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2583
Country	:	US
Telephone Number	:	805-489-4026
Fax Number	:

Provider Business Practice Location Address
First Line	:	1152 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2583
Country	:	US
Telephone Number	:	805-489-4026
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	11/29/2011

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