Provider Demographics
NPI:1386137016
Name:ANDERSON, JACQUELINE R (PHD, NCSP, LP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD, NCSP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 AIRPORT WAY STE 125
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-2729
Mailing Address - Country:US
Mailing Address - Phone:970-310-3406
Mailing Address - Fax:
Practice Address - Street 1:12303 AIRPORT WAY STE 125
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-2729
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005796103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool