Provider Demographics
NPI:1467719443
Name:WELLS-CHAKNOVA, JANE (PHD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:WELLS-CHAKNOVA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:2500 30TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1238
Mailing Address - Country:US
Mailing Address - Phone:303-546-9699
Mailing Address - Fax:303-648-5715
Practice Address - Street 1:2500 30TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1238
Practice Address - Country:US
Practice Address - Phone:303-546-9699
Practice Address - Fax:303-648-5715
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1876103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist