Provider Demographics
NPI:1528643848
Name:KALLAN, JACOB RICHARD
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RICHARD
Last Name:KALLAN
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 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2421
Mailing Address - Fax:970-490-4156
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-495-8020
Practice Address - Fax:970-495-7686
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2024-10-18
Deactivation Date:2024-06-21
Deactivation Code:
Reactivation Date:2024-10-15
Provider Licenses
StateLicense IDTaxonomies
COLPC.00020835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional