MEDICARE: MS. JACKIE MELTZ 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	19132	CA

General Provider Information

NPI Number	:	1922188036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACKIE MELTZ LCSW

Provider Business Mailing Address
First Line	:	5350 MANHATTAN CIR STE 237
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-4272
Country	:	US
Telephone Number	:	310-963-2541
Fax Number	:

Provider Business Practice Location Address
First Line	:	5350 MANHATTAN CIR STE 237
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-4272
Country	:	US
Telephone Number	:	310-963-2541
Fax Number	:

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	10/22/2019

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