Healthcare Provider Details

I. General information

NPI: 1154966174
Provider Name (Legal Business Name): JESSICA DACIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 RIVERBEND RD STE 100
BOULDER CO
80301-2633
US

IV. Provider business mailing address

PO BOX 9049
BOULDER CO
80301-9049
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-4045
  • Fax: 303-415-4046
Mailing address:
  • Phone: 303-415-4045
  • Fax: 303-415-4046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1618824
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPN-0995233-CNM
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: