1174560999 NPI number — JENNIFER LIANI SLACK LCSW

Table of content: JENNIFER LIANI SLACK LCSW (NPI 1174560999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174560999 NPI number — JENNIFER LIANI SLACK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLACK
Provider First Name:
JENNIFER
Provider Middle Name:
LIANI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEESON
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LIANI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174560999
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4851 INDEPENDENCE ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-6715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-425-0300
Provider Business Mailing Address Fax Number:
303-432-5071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7828 VANCE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ARVADA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80003-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-425-0300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  1047 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)