Provider Demographics
NPI:1043798143
Name:UNDEM, KJERSTEN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KJERSTEN
Middle Name:ELIZABETH
Last Name:UNDEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 EDINBURGH ST APT A7
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2240
Mailing Address - Country:US
Mailing Address - Phone:320-224-2879
Mailing Address - Fax:
Practice Address - Street 1:1613 PROSPECT PARK WAY STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9707
Practice Address - Country:US
Practice Address - Phone:970-377-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician