Provider Demographics
NPI:1215755194
Name:NILES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 KELLY JOHNSON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3930
Mailing Address - Country:US
Mailing Address - Phone:720-326-8644
Mailing Address - Fax:
Practice Address - Street 1:1785 N ACADEMY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-2733
Practice Address - Country:US
Practice Address - Phone:719-941-5066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health