Provider Demographics
NPI:1225121767
Name:ABBOTT, JEANNINE K (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:K
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ALHAMBRA PL
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-6245
Mailing Address - Country:US
Mailing Address - Phone:614-354-6336
Mailing Address - Fax:
Practice Address - Street 1:115 ALHAMBRA PL
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-6245
Practice Address - Country:US
Practice Address - Phone:614-354-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2025-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5891103T00000X
OHP.5891103TC0700X, 103TH0004X
CO5789103TH0004X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083266Medicaid
OH0083266Medicaid