Provider Demographics
NPI:1770114324
Name:ROGERS, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-0323
Mailing Address - Country:US
Mailing Address - Phone:719-510-5004
Mailing Address - Fax:
Practice Address - Street 1:524 N TEJON ST STE 3
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4926
Practice Address - Country:US
Practice Address - Phone:719-510-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical