Provider Demographics
NPI:1023010691
Name:LIPSON, JONATHAN MARK (PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
Last Name:LIPSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-0478
Mailing Address - Country:US
Mailing Address - Phone:303-916-1952
Mailing Address - Fax:303-278-4981
Practice Address - Street 1:1746 COLE BLVD
Practice Address - Street 2:BUILDING 21, SUITE 295
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3208
Practice Address - Country:US
Practice Address - Phone:303-916-1952
Practice Address - Fax:303-278-4981
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2129103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07021298Medicaid
LIA53624OtherBLUE CROSS BLUE SHIELD
468568Medicare ID - Type Unspecified