Provider Demographics
NPI:1093876484
Name:KLOCK, JIM R (LCSW)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:R
Last Name:KLOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 TOPANGA CT
Mailing Address - Street 2:
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-6278
Mailing Address - Country:US
Mailing Address - Phone:970-495-4853
Mailing Address - Fax:970-204-7883
Practice Address - Street 1:760 WHALERS WAY
Practice Address - Street 2:SUITE C-200
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3370
Practice Address - Country:US
Practice Address - Phone:970-495-4853
Practice Address - Fax:970-204-7883
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9891631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical