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General NPI Number Information
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NPI Number | 1851170856
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Entity Type | Organization
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Legal Business Name | FOUNTAIN VALLEY HEALTH CARE LLC
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Dates
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Enumeration Date | 09/27/2023
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Last Update Date | 09/27/2023
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Provider Practice Location Address
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Address Line | 1520 VERDE DR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80910-1931
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Country | US
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Telephone | 719-653-7776
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Fax |
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Provider Business Mailing Address
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Address Line | 1259 LAKE PLAZA DR STE 270
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-3560
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACQUITA LOUISE JORDAN
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Credential | DNP
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Telephone | 719-653-7776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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