Provider Demographics
NPI:1013373679
Name:JEFFERSON CENTER FOR MENTAL HEALTH
Entity Type:Organization
Organization Name:JEFFERSON CENTER FOR MENTAL HEALTH
Other - Org Name:BLUE SPRUCE PHARMACY AT INDEPENDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSMEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-432-5725
Mailing Address - Street 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-432-5725
Mailing Address - Fax:303-432-5724
Practice Address - Street 1:4851 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-432-5725
Practice Address - Fax:303-432-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1680000103333600000X
3336C0002X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04680057Medicaid
2157466OtherPK