Provider Demographics
NPI:1790831964
Name:SIMON, MARY JACQUELINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JACQUELINE
Last Name:SIMON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-4571
Mailing Address - Country:US
Mailing Address - Phone:303-321-1108
Mailing Address - Fax:303-316-7352
Practice Address - Street 1:3710 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-4571
Practice Address - Country:US
Practice Address - Phone:303-321-1108
Practice Address - Fax:303-316-7352
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1287103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC80916Medicare PIN