MEDICARE: JACQUE PENFOLD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	992895	CO

General Provider Information

NPI Number	:	1396707535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUE PENFOLD LCSW

Provider Business Mailing Address
First Line	:	6021 PUMA DRIVE
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538
Country	:	US
Telephone Number	:	970-690-8429
Fax Number	:	970-669-5987

Provider Business Practice Location Address
First Line	:	1501 N. CLEVELAND AVENUE
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538
Country	:	US
Telephone Number	:	970-690-8429
Fax Number	:	970-669-5987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	07/08/2007

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