Basic Information
| Provider Information | |||||||||
| NPI: | 1588915185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONEDY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARVALHO | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.ED., BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1155 KELLY JOHNSON BLVD STE. 150 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193542582 | ||||||||
| FaxNumber: | 7204934632 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 KELLY JOHNSON BLVD STE. 150 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193542582 | ||||||||
| FaxNumber: | 7204934632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2012 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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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 | 103K00000X | 1-12-11883 | HI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 46473041 | 05 | CO | MEDICAID |