Healthcare Provider Details

I. General information

NPI: 1417421025
Provider Name (Legal Business Name): JACKSON CREEK ASSISTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 JACKSON CREEK PARKWAY
MONUMENT CO
80132
US

IV. Provider business mailing address

12136 W BAYAUD AVE STE 200
LAKEWOOD CO
80228-2115
US

V. Phone/Fax

Practice location:
  • Phone: 719-725-6060
  • Fax: 303-987-0434
Mailing address:
  • Phone: 303-238-3838
  • Fax: 303-987-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MARY KORETKE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 303-238-3838