Healthcare Provider Details

I. General information

NPI: 1972792802
Provider Name (Legal Business Name): JON EASTON DENNIG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 E EXPOSITION AVE SUITE 408
DENVER CO
80209
US

IV. Provider business mailing address

3955 E EXPOSITION AVE
DENVER CO
80209
US

V. Phone/Fax

Practice location:
  • Phone: 303-519-9479
  • Fax: 303-871-0992
Mailing address:
  • Phone: 303-519-9479
  • Fax: 303-871-0992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3515
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number797
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3515
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: