Basic Information
| Provider Information | |||||||||
| NPI: | 1558400051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARGROVE | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6210 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874996210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092258 | ||||||||
| FaxNumber: | 5056092259 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092000 | ||||||||
| FaxNumber: | 5056092259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 01/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A87959 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 45957 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD2009-0130 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A879590 | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER | 78401054 | 05 | CO | MEDICAID |