Provider Demographics
NPI:1083623235
Name:RISTAU, JACQUE ANN (MS)
Entity Type:Individual
Prefix:MRS
First Name:JACQUE
Middle Name:ANN
Last Name:RISTAU
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W ASH ST
Mailing Address - Street 2:STE D
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-4652
Mailing Address - Country:US
Mailing Address - Phone:970-222-7249
Mailing Address - Fax:970-267-0830
Practice Address - Street 1:1200 W ASH ST
Practice Address - Street 2:STE D
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-4652
Practice Address - Country:US
Practice Address - Phone:970-222-7249
Practice Address - Fax:970-267-0830
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional