Provider Demographics
NPI:1154052645
Name:TERRELL, JACLYN (SSP, NCSP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11861 CHAMBERS DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-9334
Mailing Address - Country:US
Mailing Address - Phone:979-236-6758
Mailing Address - Fax:
Practice Address - Street 1:11861 CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-9334
Practice Address - Country:US
Practice Address - Phone:979-236-6758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261731103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool