Healthcare Provider Details

I. General information

NPI: 1073483889
Provider Name (Legal Business Name): JEREMY GARDNER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 ROCKY MOUNTAIN AVE STE 260
LOVELAND CO
80538-9075
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 260
LOVELAND CO
80538-9075
US

V. Phone/Fax

Practice location:
  • Phone: 720-712-0306
  • Fax:
Mailing address:
  • Phone: 720-712-0306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0105259-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: