Provider Demographics
NPI:1093874026
Name:PROVIDENCE, CHERYL JEPSEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:JEPSEN
Last Name:PROVIDENCE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 EAST ARAPAHOE ROAD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112
Mailing Address - Country:US
Mailing Address - Phone:303-741-1077
Mailing Address - Fax:303-741-1078
Practice Address - Street 1:7400 EAST ARAPAHOE ROAD
Practice Address - Street 2:SUITE 212
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112
Practice Address - Country:US
Practice Address - Phone:303-741-1077
Practice Address - Fax:303-741-1078
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2307103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80529046Medicaid
CO473738Medicare ID - Type Unspecified
COC473738Medicare PIN