Provider Demographics
NPI:1487958070
Name:JANKELOW, MARK (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JANKELOW
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4023
Mailing Address - Country:US
Mailing Address - Phone:719-766-8511
Mailing Address - Fax:719-208-7731
Practice Address - Street 1:1318 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4023
Practice Address - Country:US
Practice Address - Phone:719-766-8511
Practice Address - Fax:719-208-7731
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COANP0990467363LC1500X
COAPN.0990467-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87108518Medicaid
CO87108518Medicaid