Healthcare Provider Details

I. General information

NPI: 1225856867
Provider Name (Legal Business Name): MAC ANDREW JACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 VALMONT RD STE 204
BOULDER CO
80301
US

IV. Provider business mailing address

2919 VALMONT RD STE 204
BOULDER CO
80301
US

V. Phone/Fax

Practice location:
  • Phone: 303-938-1110
  • Fax: 303-938-1145
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberCO-2847
License Number StateCO

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: