Healthcare Provider Details

I. General information

NPI: 1063138121
Provider Name (Legal Business Name): JORDAN ANTHONY YATES LPC, ATR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6654 GUNPARK DR STE 200F
BOULDER CO
80301-3384
US

IV. Provider business mailing address

5126 WILLIAMS FORK TRL APT 205
BOULDER CO
80301-6607
US

V. Phone/Fax

Practice location:
  • Phone: 303-990-7380
  • Fax:
Mailing address:
  • Phone: 303-990-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number22-477
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0020902
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: