Provider Demographics
NPI:1568975076
Name:FAGERHOLM, JONATHAN L
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:FAGERHOLM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 IOWA AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5947
Mailing Address - Country:US
Mailing Address - Phone:719-358-7228
Mailing Address - Fax:
Practice Address - Street 1:112 IOWA AVE STE 4
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5947
Practice Address - Country:US
Practice Address - Phone:719-358-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0105760101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)