Basic Information
| Provider Information | |||||||||
| NPI: | 1417421025 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON CREEK ASSISTED LIVING, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12136 W BAYAUD AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032383838 | ||||||||
| FaxNumber: | 3039870434 | ||||||||
| Practice Location | |||||||||
| Address1: | 16601 JACKSON CREEK PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MONUMENT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197256060 | ||||||||
| FaxNumber: | 3039870434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2019 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KORETKE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3032383838 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.