Provider Demographics
NPI:1225890619
Name:FOUNTAIN VALLEY HEALTH CARE LLC
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY HEALTH CARE LLC
Other - Org Name:FOUNTAIN VALLEY BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUITA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:719-358-7338
Mailing Address - Street 1:1259 LAKE PLAZA DR STE 270
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3560
Mailing Address - Country:US
Mailing Address - Phone:719-653-7776
Mailing Address - Fax:
Practice Address - Street 1:1259 LAKE PLAZA DR STE 270
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3560
Practice Address - Country:US
Practice Address - Phone:719-653-7776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNTAIN VALLEY HEALTH CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-30
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty