Healthcare Provider Details

I. General information

NPI: 1194966234
Provider Name (Legal Business Name): ANNABEL H JEPSEN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26996 COUNTY ROAD 65
MOFFAT CO
81143-9756
US

IV. Provider business mailing address

26996 COUNTY ROAD 65
MOFFAT CO
81143-9756
US

V. Phone/Fax

Practice location:
  • Phone: 719-580-0678
  • Fax:
Mailing address:
  • Phone: 719-580-0678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5105
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: