Provider Demographics
NPI:1053763722
Name:CHARBONNEAU, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:CHARBONNEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 WESTSHORE WAY
Mailing Address - Street 2:D13
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3217
Mailing Address - Country:US
Mailing Address - Phone:970-778-1777
Mailing Address - Fax:
Practice Address - Street 1:123 AYLESWORTH HALL
Practice Address - Street 2:CSUHN COUNSELING CENTER
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521
Practice Address - Country:US
Practice Address - Phone:970-491-6053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health