Provider Demographics
NPI:1790843787
Name:JEFFERSON COUNTY COLORADO
Entity type:Organization
Organization Name:JEFFERSON COUNTY COLORADO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC SERVICES DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-258-5492
Mailing Address - Street 1:645 PARFET ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-5574
Mailing Address - Country:US
Mailing Address - Phone:303-271-5700
Mailing Address - Fax:303-271-5702
Practice Address - Street 1:645 PARFET ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-5574
Practice Address - Country:US
Practice Address - Phone:303-271-5700
Practice Address - Fax:303-271-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251K00000X
261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04412094Medicaid
CO71504346Medicaid
CO04005567Medicaid
CO80335730Medicaid
CO288106OtherMEDICARE PTAN