Basic Information
| Provider Information | |||||||||
| NPI: | 1053763722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARBONNEAU | ||||||||
| FirstName: | JESSIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4255 WESTSHORE WAY | ||||||||
| Address2: | D13 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805253217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707781777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 AYLESWORTH HALL | ||||||||
| Address2: | CSUHN COUNSELING CENTER | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704916053 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.