Basic Information
| Provider Information | |||||||||
| NPI: | 1609342302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROEDER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1031 E 1ST AVE APT 901 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800203728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088910670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11698 HURON ST UNIT 106 | ||||||||
| Address2: | |||||||||
| City: | NORTHGLENN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802342950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203810264 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 07/08/2019 | ||||||||
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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 | 106S00000X | N | 103K00000X | 1-19-36639 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.