Healthcare Provider Details

I. General information

NPI: 1013373679
Provider Name (Legal Business Name): JEFFERSON CENTER FOR MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
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
WHEAT RIDGE CO
80033-6715
US

V. Phone/Fax

Practice location:
  • Phone: 303-432-5725
  • Fax: 303-432-5724
Mailing address:
  • Phone: 303-432-5725
  • Fax: 303-432-5724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1680000103
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW VANDER KOOI
Title or Position: DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 303-432-5725