Provider Demographics
NPI:1962643759
Name:GADDIS, JAYSON (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:GADDIS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 MARINE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1027
Mailing Address - Country:US
Mailing Address - Phone:303-818-8411
Mailing Address - Fax:
Practice Address - Street 1:2825 MARINE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1027
Practice Address - Country:US
Practice Address - Phone:303-818-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4716101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional