MEDICARE: JLK WELLNESS LLC

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	1041C0700X	Clinical Social Worker	CSW.09923802	CO

General Provider Information

NPI Number	:	1306394366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JLK WELLNESS LLC

Provider Business Mailing Address
First Line	:	1001 E BAYAUD AVE
Second Line	:	APT 1107
City	:	DENVER
State	:	CO
Zip	:	80209-2303
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 E BAYAUD AVE
Second Line	:	APT 1107
City	:	DENVER
State	:	CO
Zip	:	80209-2303
Country	:	US
Telephone Number	:	860-573-6753
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/SOLE MEMBER
Name	:	JESSICA LYNN KONIOR
Credential	:
Telephone Number	:	860-573-6753

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	09/19/2016

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