Provider Demographics
NPI:1548337249
Name:MCCARTHY, JENNIFER L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7837
Practice Address - Street 1:34 HYBROOK RD SOUTH
Practice Address - Street 2:
Practice Address - City:DIVIDE
Practice Address - State:CO
Practice Address - Zip Code:80814
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7817
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103485363A00000X
CO2997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA101228OtherMEDICARE NUMBER
CO46681230Medicaid
FL57561ZOtherMEDICARE