MEDICARE: JACQUELINE ATHENE LOUNSBURY MA, MFTC, R-DMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist		CO

General Provider Information

NPI Number	:	1346988268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE ATHENE LOUNSBURY MA, MFTC, R-DMT

Provider Business Mailing Address
First Line	:	112 RUTGERS AVE APT 205
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1444
Country	:	US
Telephone Number	:	781-266-8512
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 REMINGTON DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-1444
Country	:	US
Telephone Number	:	970-666-0565
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2022
Last Update Date	:	07/23/2024

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