Healthcare Provider Details

I. General information

NPI: 1649420993
Provider Name (Legal Business Name): MATTHEW JAECKEL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

1333 IRIS AVE
BOULDER CO
80304-2226
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1066
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1066
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: