Healthcare Provider Details

I. General information

NPI: 1023010691
Provider Name (Legal Business Name): JONATHAN MARK LIPSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1746 COLE BLVD BUILDING 21, SUITE 295
LAKEWOOD CO
80401-3208
US

IV. Provider business mailing address

PO BOX 478
CONIFER CO
80433-0478
US

V. Phone/Fax

Practice location:
  • Phone: 303-916-1952
  • Fax: 303-278-4981
Mailing address:
  • Phone: 303-916-1952
  • Fax: 303-278-4981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2129
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2129
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: