Healthcare Provider Details

I. General information

NPI: 1063793289
Provider Name (Legal Business Name): JENNIFER E. DERAAD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 E STUART ST STE 202
FORT COLLINS CO
80525-1195
US

IV. Provider business mailing address

1136 E STUART ST STE 202
FORT COLLINS CO
80525-1195
US

V. Phone/Fax

Practice location:
  • Phone: 970-829-1129
  • Fax:
Mailing address:
  • Phone: 970-829-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12614-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0995434
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: