Provider Demographics
NPI:1477968170
Name:INNIS, JERI
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:INNIS
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 1:3830 BROADWAY ST APT 31
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1243
Mailing Address - Country:US
Mailing Address - Phone:925-330-9608
Mailing Address - Fax:
Practice Address - Street 1:529 COFFMAN ST STE 300
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5450
Practice Address - Country:US
Practice Address - Phone:303-684-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional