Provider Demographics
NPI:1073179131
Name:CARSON, JANA MARIE
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:MARIE
Last Name:CARSON
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 1:2001 S SHIELDS ST BUILDING K
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1838
Mailing Address - Country:US
Mailing Address - Phone:970-472-4133
Mailing Address - Fax:970-493-6655
Practice Address - Street 1:2001 S. SHIELDS ST. BLD K
Practice Address - Street 2:
Practice Address - City:FT. COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526
Practice Address - Country:US
Practice Address - Phone:970-472-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFTC.0013837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist