Healthcare Provider Details

I. General information

NPI: 1225294895
Provider Name (Legal Business Name): JENNIFER DAWN MADDOX LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 UINTA WAY SUITE 120
DENVER CO
80230-7110
US

IV. Provider business mailing address

2575 DEXTER ST
DENVER CO
80207-3152
US

V. Phone/Fax

Practice location:
  • Phone: 303-344-4100
  • Fax: 303-484-3575
Mailing address:
  • Phone: 303-748-5597
  • Fax: 303-484-3575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10352
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number427
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: