Healthcare Provider Details

I. General information

NPI: 1558884692
Provider Name (Legal Business Name): JENNIFER L ROBERTSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 JET WING DR
COLORADO SPRINGS CO
80916-2332
US

IV. Provider business mailing address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax:
Mailing address:
  • Phone: 208-828-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7177
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-39561
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number17052
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: