Healthcare Provider Details

I. General information

NPI: 1568975076
Provider Name (Legal Business Name): JONATHAN L FAGERHOLM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 IOWA AVE STE 4
COLORADO SPRINGS CO
80909-5947
US

IV. Provider business mailing address

112 IOWA AVE STE 4
COLORADO SPRINGS CO
80909-5947
US

V. Phone/Fax

Practice location:
  • Phone: 719-358-7228
  • Fax:
Mailing address:
  • Phone: 719-358-7228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberNLC.0105760
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: