Provider Demographics
NPI:1376999516
Name:COTHRON, JENNIFER (NP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COTHRON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1587 NW WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1085
Practice Address - Country:US
Practice Address - Phone:541-476-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28188603A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201394830Medicaid
INP01723962OtherRR MEDICARE
IN266180739Medicare PIN