Basic Information
| Provider Information | |||||||||
| NPI: | 1174675953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLOCK | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MA, CACIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816020040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709452241 | ||||||||
| FaxNumber: | 9709455523 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 28 3/4 RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815015016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702416023 | ||||||||
| FaxNumber: | 9702428330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 7152 | CO | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.