Healthcare Provider Details

I. General information

NPI: 1649674524
Provider Name (Legal Business Name): JENNIFER E MEDINA PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 PECOS ST STE 150
DENVER CO
80211-2561
US

IV. Provider business mailing address

4045 PECOS ST STE 150
DENVER CO
80211-2561
US

V. Phone/Fax

Practice location:
  • Phone: 720-295-0357
  • Fax:
Mailing address:
  • Phone: 720-295-0357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY.0004192
License Number StateCO

VIII. Authorized Official

Name: JENNIFER MEDINA
Title or Position: OWNER
Credential: PHD
Phone: 720-295-0357