Provider Demographics
NPI:1316562754
Name:COLE, JACESON (LCSW)
Entity Type:Individual
Prefix:
First Name:JACESON
Middle Name:
Last Name:COLE
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:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:OURAY
Mailing Address - State:CO
Mailing Address - Zip Code:81427-1024
Mailing Address - Country:US
Mailing Address - Phone:318-491-1619
Mailing Address - Fax:
Practice Address - Street 1:533 8TH AVE #1024
Practice Address - Street 2:
Practice Address - City:OURAY
Practice Address - State:CO
Practice Address - Zip Code:81427-8142
Practice Address - Country:US
Practice Address - Phone:318-491-1619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099245801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical