Provider Demographics
NPI:1225678253
Name:STILLEY, JENNIFER MADDOCKS
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MADDOCKS
Last Name:STILLEY
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 1:5888 CUMBRE VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-6011
Mailing Address - Country:US
Mailing Address - Phone:719-358-3552
Mailing Address - Fax:
Practice Address - Street 1:6760 CORPORATE DR STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-5910
Practice Address - Country:US
Practice Address - Phone:719-357-7651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0110277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health