Basic Information
Provider Information | |||||||||
NPI: | 1063882298 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JEWISH FAMILY SERVICE OF COLORADO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SHALOM DENVER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3201 S TAMARAC DR | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802314360 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3035975000 | ||||||||
FaxNumber: | 3035975009 | ||||||||
Practice Location | |||||||||
Address1: | 2498 W 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802231007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036230251 | ||||||||
FaxNumber: | 3036209584 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2015 | ||||||||
LastUpdateDate: | 07/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOSTER | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 3035975000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X |   |   | Y |   | Agencies | Day Training, Developmentally Disabled Services |   |
ID Information
ID | Type | State | Issuer | Description | 64051064 | 05 | CO |   | MEDICAID |