Provider Demographics
NPI:1790459725
Name:TOLBERT, JACINDA MARIE
Entity Type:Individual
Prefix:
First Name:JACINDA
Middle Name:MARIE
Last Name:TOLBERT
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 1:2005 AEROPLAZA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-4207
Mailing Address - Country:US
Mailing Address - Phone:719-425-7771
Mailing Address - Fax:
Practice Address - Street 1:2005 AEROPLAZA DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-4207
Practice Address - Country:US
Practice Address - Phone:719-425-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21177460106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician