Provider Demographics
NPI:1215550447
Name:JACKIE LYNCH, LLC
Entity Type:Organization
Organization Name:JACKIE LYNCH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:970-412-2632
Mailing Address - Street 1:1713 WESTCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2980
Mailing Address - Country:US
Mailing Address - Phone:203-554-9309
Mailing Address - Fax:
Practice Address - Street 1:1502 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4116
Practice Address - Country:US
Practice Address - Phone:970-412-2632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health