Provider Demographics
NPI:1316713134
Name:RIDDELL-KAUFMAN, JEREMY (LPC, MA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:RIDDELL-KAUFMAN
Suffix:
Gender:M
Credentials:LPC, MA
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:GILDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC, MA
Mailing Address - Street 1:2216 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7542
Mailing Address - Country:US
Mailing Address - Phone:831-601-8978
Mailing Address - Fax:
Practice Address - Street 1:2216 24TH AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7542
Practice Address - Country:US
Practice Address - Phone:831-601-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019935101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health