Provider Demographics
NPI:1073379376
Name:MARMOLEJO, JOSE ALFREDO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFREDO
Last Name:MARMOLEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 RED DAWN DR APT B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80902-3266
Mailing Address - Country:US
Mailing Address - Phone:915-301-4484
Mailing Address - Fax:
Practice Address - Street 1:8415 EXPLORER DR APT B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1033
Practice Address - Country:US
Practice Address - Phone:915-301-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician