MEDICARE: MS. JUTHARAT MCCORMACK LPC, RN, CAC III

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	163W00000X	Registered Nurse	162465	CO
2	101YP2500X	Professional Counselor	6391	CO
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	7138	CO

General Provider Information

NPI Number	:	1720282155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUTHARAT MCCORMACK LPC, RN, CAC III

Provider Business Mailing Address
First Line	:	2610 STOUT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-2941
Country	:	US
Telephone Number	:	720-341-8694
Fax Number	:

Provider Business Practice Location Address
First Line	:	2610 STOUT ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-2941
Country	:	US
Telephone Number	:	303-504-1200
Fax Number	:

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/16/2012

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