Healthcare Provider Details

I. General information

NPI: 1548262066
Provider Name (Legal Business Name): JENNIFER MARIE BETTENHAUSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE PHILLIPS MD

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 SYLVAN LAKE RD SUITE 210
EAGLE CO
81631
US

IV. Provider business mailing address

PO BOX 1749 C/O CREDENTIALING-LISA KERSTIENS
EDWARDS CO
81632-1749
US

V. Phone/Fax

Practice location:
  • Phone: 970-328-1650
  • Fax: 970-328-1651
Mailing address:
  • Phone: 970-926-6340
  • Fax: 970-926-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34815
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: