Provider Demographics
NPI:1184320129
Name:JEFFERSON, MALLORY ROSE (LPC, MA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ROSE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 HOLMES DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2522
Mailing Address - Country:US
Mailing Address - Phone:719-210-6787
Mailing Address - Fax:
Practice Address - Street 1:617 N 17TH ST STE 230
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3577
Practice Address - Country:US
Practice Address - Phone:719-315-4587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020928101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional