Provider Demographics
NPI:1902005283
Name:UPSHAW, JACQUELYN L (RN,LPC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:L
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:RN,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 CORBETT DR
Mailing Address - Street 2:
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-9579
Mailing Address - Country:US
Mailing Address - Phone:970-207-4800
Mailing Address - Fax:970-207-4805
Practice Address - Street 1:4601 CORBETT DR
Practice Address - Street 2:
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-9579
Practice Address - Country:US
Practice Address - Phone:970-207-4800
Practice Address - Fax:970-207-4805
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional