Healthcare Provider Details

I. General information

NPI: 1790476703
Provider Name (Legal Business Name): JACLYN REDAR CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 BRIARGATE PARKWAY SUITE 300
COLORADO SPRINGS CO
80920-7837
US

IV. Provider business mailing address

4110 BRIARGATE PARKWAY SUITE 300
COLORADO SPRINGS CO
80920-7837
US

V. Phone/Fax

Practice location:
  • Phone: 719-867-7335
  • Fax: 719-867-7311
Mailing address:
  • Phone: 719-867-7335
  • Fax: 719-867-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: