Basic Information
| Provider Information | |||||||||
| NPI: | 1144513821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2949 FEDERAL BLVD STE 231 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802113741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209070420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4141 E DICKENSON PL | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802226012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035046650 | ||||||||
| FaxNumber: | 3035046905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2011 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY.0004192 | CO | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PSY.0004192 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.