Healthcare Provider Details

I. General information

NPI: 1386017812
Provider Name (Legal Business Name): JENILLE ANN GUDAHL LPC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENILLE LOVELACE

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BELFORD AVE STE 200A
GRAND JCT CO
81501-3100
US

IV. Provider business mailing address

598 SHOSHONE ST
GRAND JCT CO
81504-5681
US

V. Phone/Fax

Practice location:
  • Phone: 970-361-1038
  • Fax:
Mailing address:
  • Phone: 970-361-1038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0015498
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0000936
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: