Provider Demographics
NPI:1780129288
Name:JESICCA NICOLE KRUCKEBERG
Entity type:Organization
Organization Name:JESICCA NICOLE KRUCKEBERG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUKEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-360-9935
Mailing Address - Street 1:2101 S BLACKHAWK ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1492
Mailing Address - Country:US
Mailing Address - Phone:612-360-9935
Mailing Address - Fax:
Practice Address - Street 1:2101 S BLACKHAWK ST
Practice Address - Street 2:SUITE 240
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1492
Practice Address - Country:US
Practice Address - Phone:612-360-9935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001336106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty