Provider Demographics
NPI:1316246937
Name:WELLS, JACK RANDELL (PSYD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:RANDELL
Last Name:WELLS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 ELKTON DR STE 301
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3884
Mailing Address - Country:US
Mailing Address - Phone:719-357-6471
Mailing Address - Fax:719-631-2526
Practice Address - Street 1:1115 ELKTON DR STE 301
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3884
Practice Address - Country:US
Practice Address - Phone:719-357-6471
Practice Address - Fax:719-631-2526
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical