Provider Demographics
NPI:1922117621
Name:PEDERSEN, JANE C (LCSW)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:C
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 MAIN AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5369
Mailing Address - Country:US
Mailing Address - Phone:970-385-5266
Mailing Address - Fax:615-296-2773
Practice Address - Street 1:1075 MAIN AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5369
Practice Address - Country:US
Practice Address - Phone:970-385-5266
Practice Address - Fax:615-296-2773
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4607101YA0400X
CO560101YM0800X
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO560OtherLICCLINICALSOCIALWORKER
CO806777Medicare PIN