Basic Information
| Provider Information | |||||||||
| NPI: | 1194310417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEFFERSON CENTER FOR MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4851 INDEPENDENCE ST | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800336715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034250300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 421 ZANG ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039894357 | ||||||||
| FaxNumber: | 3039882017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2021 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOFF | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3034325164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.