Healthcare Provider Details

I. General information

NPI: 1053682385
Provider Name (Legal Business Name): JENNIFER WORTMANN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 24TH ST STE 100
PUEBLO CO
81003-1411
US

IV. Provider business mailing address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

V. Phone/Fax

Practice location:
  • Phone: 719-320-0481
  • Fax:
Mailing address:
  • Phone: 719-546-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0991123
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number161849
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: