Healthcare Provider Details

I. General information

NPI: 1225890619
Provider Name (Legal Business Name): FOUNTAIN VALLEY HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 FONTAINE BLVD
FOUNTAIN CO
80817-1061
US

IV. Provider business mailing address

10265 ROLLING RIDGE RD
COLORADO SPRINGS CO
80925-9509
US

V. Phone/Fax

Practice location:
  • Phone: 719-653-7776
  • Fax:
Mailing address:
  • Phone: 719-653-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JACQUITA LOUISE JORDAN
Title or Position: OWNER
Credential: DNP
Phone: 719-358-7338