Provider Demographics
NPI:1396707535
Name:PENFOLD, JACQUE (LCSW)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:PENFOLD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 PUMA DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538
Mailing Address - Country:US
Mailing Address - Phone:970-690-8429
Mailing Address - Fax:970-669-5987
Practice Address - Street 1:1501 N. CLEVELAND AVENUE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538
Practice Address - Country:US
Practice Address - Phone:970-690-8429
Practice Address - Fax:970-669-5987
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9928951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC498088Medicare ID - Type UnspecifiedMEDICARE
COC502038Medicare ID - Type UnspecifiedMEDICARE