Basic Information
| Provider Information | |||||||||
| NPI: | 1508454596 | ||||||||
| 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 | ||||||||
| FaxNumber: | 3034325071 | ||||||||
| Practice Location | |||||||||
| Address1: | 10295 W KEENE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802351104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039804082 | ||||||||
| FaxNumber: | 3039804084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOFF | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3034325164 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 45175233 | 05 | CO | MEDICAID |