Provider Demographics
NPI:1790310571
Name:GRANBERG, JEAN M
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:GRANBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 6429 CIR
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81403-7148
Mailing Address - Country:US
Mailing Address - Phone:970-249-7887
Mailing Address - Fax:
Practice Address - Street 1:2731 COMMERCIAL WAY UNIT C
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5700
Practice Address - Country:US
Practice Address - Phone:970-364-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0110404101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0110404OtherDORA