MEDICARE: JIM R KLOCK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	989163	CO

General Provider Information

NPI Number	:	1093876484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIM R KLOCK LCSW

Provider Business Mailing Address
First Line	:	1907 TOPANGA CT
Second Line	:
City	:	FT COLLINS
State	:	CO
Zip	:	80528-6278
Country	:	US
Telephone Number	:	970-495-4853
Fax Number	:	970-204-7883

Provider Business Practice Location Address
First Line	:	760 WHALERS WAY
Second Line	:	SUITE C-200
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3370
Country	:	US
Telephone Number	:	970-495-4853
Fax Number	:	970-204-7883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/08/2007

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