Healthcare Provider Details

I. General information

NPI: 1053093674
Provider Name (Legal Business Name): JENNIFER LYNN BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 N UNION BLVD STE 201A
COLORADO SPRINGS CO
80918-2069
US

IV. Provider business mailing address

17035 BLUE MIST GRV
MONUMENT CO
80132-8639
US

V. Phone/Fax

Practice location:
  • Phone: 719-401-1822
  • Fax:
Mailing address:
  • Phone: 719-401-1822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0023757
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: