Healthcare Provider Details

I. General information

NPI: 1275272924
Provider Name (Legal Business Name): FOUNTAIN VALLEY HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2022
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: 719-271-2887
  • Fax:
Mailing address:
  • Phone: 719-271-2887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUITA JORDAN
Title or Position: OWNER
Credential: FNP
Phone: 719-271-2887