Basic Information
| Provider Information | |||||||||
| NPI: | 1326567363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLODSTROM | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | |||||||||
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| Credential: | CAC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 W HWY 50 | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812012238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195396502 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 W HWY 50 | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195396502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2017 | ||||||||
| LastUpdateDate: | 11/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | ACB.0008406 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.