Provider Demographics
NPI:1972682045
Name:COLBURN, JEANETTE MARIE (AUD)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:MARIE
Last Name:COLBURN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:JEANETTE
Other - Middle Name:MARIE
Other - Last Name:COLBURN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AUD
Mailing Address - Street 1:803 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4419
Mailing Address - Country:US
Mailing Address - Phone:307-721-9527
Mailing Address - Fax:
Practice Address - Street 1:803 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4419
Practice Address - Country:US
Practice Address - Phone:307-721-9527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-943231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP00165925Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WY20045Medicare ID - Type Unspecified