Healthcare Provider Details

I. General information

NPI: 1073179131
Provider Name (Legal Business Name): JANA MARIE CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S. SHIELDS ST. BLD K
FT. COLLINS CO
80526
US

IV. Provider business mailing address

2001 S SHIELDS ST BUILDING K
FORT COLLINS CO
80526-1838
US

V. Phone/Fax

Practice location:
  • Phone: 970-472-4133
  • Fax:
Mailing address:
  • Phone: 970-472-4133
  • Fax: 970-493-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTC.0013837
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: