Healthcare Provider Details

I. General information

NPI: 1659588101
Provider Name (Legal Business Name): JACQUELINE SUE VANDENBOVENKAMP MA-LPC-ATR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 19TH ST LOT 190
BOULDER CO
80304-0613
US

IV. Provider business mailing address

4500 19TH ST LOT 190
BOULDER CO
80304-0613
US

V. Phone/Fax

Practice location:
  • Phone: 303-641-2718
  • Fax:
Mailing address:
  • Phone: 303-641-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3918
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number05-132
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: