Provider Demographics
NPI:1609522721
Name:ARCHULETA, JENNIFER (LPC LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:LPC LAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MOUDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC LAC
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-463-5600
Mailing Address - Fax:
Practice Address - Street 1:2 S CASCADE AVE STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1604
Practice Address - Country:US
Practice Address - Phone:719-463-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000403101YA0400X
COLPC.0011605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)