Provider Demographics
NPI:1902422801
Name:MEDINA, JENNIFER (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1926
Mailing Address - Street 2:
Mailing Address - City:IDAHO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80452-1926
Mailing Address - Country:US
Mailing Address - Phone:720-587-9702
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE 4262
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:720-924-7268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0996767-NP363LP0808X
WAAP61426583363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health