Provider Demographics
NPI:1972822609
Name:THEOBALD, JEANNE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARIE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:MARIE
Other - Last Name:GRADOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 S JACKSON ST STE 240
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3131
Mailing Address - Country:US
Mailing Address - Phone:720-724-3668
Mailing Address - Fax:720-598-0480
Practice Address - Street 1:300 S JACKSON ST STE 240
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3131
Practice Address - Country:US
Practice Address - Phone:720-724-3668
Practice Address - Fax:720-598-0480
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR 00520282084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry