MEDICARE: LORIELLE M JACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	DH002024003	CO

General Provider Information

NPI Number	:	1235594169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORIELLE M JACK

Provider Business Mailing Address
First Line	:	185 SUTTLE ST
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81303-8276
Country	:	US
Telephone Number	:	970-335-2232
Fax Number	:	970-677-2540

Provider Business Practice Location Address
First Line	:	2530 COLORADO AVE UNIT 1A
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-4761
Country	:	US
Telephone Number	:	970-335-2442
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2015
Last Update Date	:	01/02/2020

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