Provider Demographics
NPI:1548331283
Name:CODY, JENNIFER L (DC)
Entity type:Individual
Prefix:PROF
First Name:JENNIFER
Middle Name:L
Last Name:CODY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PUEBLO BOULEVARD WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1687
Mailing Address - Country:US
Mailing Address - Phone:719-584-2692
Mailing Address - Fax:
Practice Address - Street 1:1111 PUEBLO BOULEVARD WAY STE 110
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1687
Practice Address - Country:US
Practice Address - Phone:719-584-2692
Practice Address - Fax:719-584-2692
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU55432Medicare UPIN
COC29403Medicare ID - Type UnspecifiedMEDICARE NUMBER