Provider Demographics
NPI:1659588101
Name:VANDENBOVENKAMP, JACQUELINE SUE (MA-LPC-ATR)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:SUE
Last Name:VANDENBOVENKAMP
Suffix:
Gender:F
Credentials:MA-LPC-ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 19TH ST
Mailing Address - Street 2:LOT 190
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0613
Mailing Address - Country:US
Mailing Address - Phone:303-641-2718
Mailing Address - Fax:
Practice Address - Street 1:4500 19TH ST
Practice Address - Street 2:LOT 190
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0613
Practice Address - Country:US
Practice Address - Phone:303-641-2718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3918101Y00000X
05-132221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist