Healthcare Provider Details

I. General information

NPI: 1487045803
Provider Name (Legal Business Name): JEFFREY WENTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

IV. Provider business mailing address

559 VINCENT ST SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-7804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0065509
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number29778
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: