Healthcare Provider Details

I. General information

NPI: 1528471166
Provider Name (Legal Business Name): JENNIFER MEDLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 01/17/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 9481 WILDERNESS RD
FT. CARSON CO
80913
US

IV. Provider business mailing address

185 BELLA VISTA LN
COLORADO SPRINGS CO
80911-2450
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-2542
  • Fax:
Mailing address:
  • Phone: 719-327-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW09924407
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number925
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: