Provider Demographics
NPI:1346988268
Name:LOUNSBURY, JACQUELINE ATHENE (MA, MFTC, R-DMT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ATHENE
Last Name:LOUNSBURY
Suffix:
Gender:F
Credentials:MA, MFTC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 RUTGERS AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1444
Mailing Address - Country:US
Mailing Address - Phone:781-266-8512
Mailing Address - Fax:
Practice Address - Street 1:111 REMINGTON DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1444
Practice Address - Country:US
Practice Address - Phone:970-666-0565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist