Provider Demographics
NPI:1740586189
Name:JEFFERSON CENTER FOR MENTAL HEALTH
Entity Type:Organization
Organization Name:JEFFERSON CENTER FOR MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-432-5164
Mailing Address - Street 1:4851 INDEPENDENCE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6712
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:303-432-5071
Practice Address - Street 1:1969 MINER STREET
Practice Address - Street 2:
Practice Address - City:IDAHO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80452
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:303-567-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO150413101YA0400X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000163761Medicaid