Basic Information
| Provider Information | |||||||||
| NPI: | 1093018236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STATLER | ||||||||
| FirstName: | JAYNE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KELLEY | ||||||||
| OtherFirstName: | JAYNE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809102522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | 7195726080 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 PARKSIDE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | 7195726399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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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 | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 6554 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.