Healthcare Provider Details

I. General information

NPI: 1154403798
Provider Name (Legal Business Name): JEFFERSON CENTER FOR MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 INDEPENDENCE ST
WHEAT RIDGE CO
80033-6715
US

IV. Provider business mailing address

4851 INDEPENDENCE ST STE 200
WHEAT RIDGE CO
80033-6712
US

V. Phone/Fax

Practice location:
  • Phone: 303-425-0300
  • Fax: 303-432-5071
Mailing address:
  • Phone: 303-425-0300
  • Fax: 303-432-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number560
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number560
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9000130227
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MR. DAVID A GOFF
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 303-432-5164