Healthcare Provider Details

I. General information

NPI: 1346586088
Provider Name (Legal Business Name): JANDYCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 COLORADO AVE STE C
PUEBLO CO
81004-2008
US

IV. Provider business mailing address

509 COLORADO AVE STE C
PUEBLO CO
81004-2008
US

V. Phone/Fax

Practice location:
  • Phone: 719-696-9828
  • Fax: 719-696-9862
Mailing address:
  • Phone: 719-214-2005
  • Fax: 719-696-9862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number44011
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number44011
License Number StateCO

VIII. Authorized Official

Name: DR. JAMIE M POLLOCK
Title or Position: OWNER/ PHYSICIAN
Credential: M.D.
Phone: 719-214-2005