Provider Demographics
NPI:1730678749
Name:CULLOM, JENNIFER (LPC, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CULLOM
Suffix:
Gender:F
Credentials:LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 18TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-9722
Mailing Address - Country:US
Mailing Address - Phone:720-204-8655
Mailing Address - Fax:
Practice Address - Street 1:2204 18TH AVE STE 140
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-9722
Practice Address - Country:US
Practice Address - Phone:720-204-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0001479101YM0800X
COLPC.0017162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health