Provider Demographics
NPI:1265143663
Name:LOVELESS, JESSICA DAWN (RBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:LOVELESS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LEADVILLE CLINIC
Mailing Address - Street 2:1609 N POPLAR ST.
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-3110
Mailing Address - Country:US
Mailing Address - Phone:720-584-8055
Mailing Address - Fax:
Practice Address - Street 1:LEADVILLE CLINIC
Practice Address - Street 2:1609 N POPLAR ST.
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461
Practice Address - Country:US
Practice Address - Phone:720-584-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-22-246779106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician