MEDICARE: JESSE JAMES EMERSON BA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1790111623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE JAMES EMERSON BA

Provider Business Mailing Address
First Line	:	14982 RANDOLPH PL
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80239-6306
Country	:	US
Telephone Number	:	303-322-7108
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 CHERRY CREEK DRIVE SOUTH
Second Line	:	SUITE 940
City	:	DENVER
State	:	CO
Zip	:	80246-1535
Country	:	US
Telephone Number	:	303-322-7108
Fax Number	:

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

Provider Enumeration Date	:	09/24/2013
Last Update Date	:	09/24/2013

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