Provider Demographics
NPI:1386017812
Name:GUDAHL, JENILLE ANN (LPC, LAC)
Entity Type:Individual
Prefix:
First Name:JENILLE
Middle Name:ANN
Last Name:GUDAHL
Suffix:
Gender:F
Credentials:LPC, LAC
Other - Prefix:
Other - First Name:JENILLE
Other - Middle Name:
Other - Last Name:LOVELACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:598 SHOSHONE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JCT
Mailing Address - State:CO
Mailing Address - Zip Code:81504-5681
Mailing Address - Country:US
Mailing Address - Phone:970-361-1038
Mailing Address - Fax:
Practice Address - Street 1:800 BELFORD AVE STE 200A
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81501-3100
Practice Address - Country:US
Practice Address - Phone:970-361-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0015498101YP2500X
COACD.0000936101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000161929Medicaid