=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922704915
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER NICOLE PEARSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2023
-----------------------------------------------------
Last Update Date | 02/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4145 FALL RIVER RD
-----------------------------------------------------
City | IDAHO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80452-9730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-437-3022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1695
-----------------------------------------------------
City | IDAHO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80452-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-437-3022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------