Provider Demographics
NPI:1871072512
Name:MYRICK, JENNIFER J (RDH)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:J
Last Name:MYRICK
Suffix:
Gender:F
Credentials:RDH
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 861
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0861
Mailing Address - Country:US
Mailing Address - Phone:920-360-1870
Mailing Address - Fax:
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4716
Practice Address - Country:US
Practice Address - Phone:970-625-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH.000904961124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO124Q00000XMedicaid