Provider Demographics
NPI:1548262066
Name:BETTENHAUSEN, JENNIFER MARIE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BETTENHAUSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1749
Mailing Address - Street 2:C/O CREDENTIALING-LISA KERSTIENS
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1749
Mailing Address - Country:US
Mailing Address - Phone:970-926-6340
Mailing Address - Fax:970-926-6348
Practice Address - Street 1:377 SYLVAN LAKE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-328-1650
Practice Address - Fax:970-328-1651
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01348150Medicaid
CO01348150Medicaid
G22370Medicare UPIN
CO301589Medicare PIN