=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740892199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA ALEXANDRA LIVESAY MFTC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 789 N SHERMAN ST # 650
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-3529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-295-1385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2920 ALBION ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80207-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-809-8250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFTC.0014019
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------