Basic Information
| Provider Information | |||||||||
| NPI: | 1851874150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGUSPACK | ||||||||
| FirstName: | JACE | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244034 | ||||||||
| FaxNumber: | 9704904347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E BOULDER ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696000994 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PSYC.00013829 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.