Provider Demographics
NPI:1326567363
Name:FLODSTROM, JILL (CAC II)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FLODSTROM
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W HWY 50
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2238
Mailing Address - Country:US
Mailing Address - Phone:719-539-6502
Mailing Address - Fax:
Practice Address - Street 1:550 W HWY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201
Practice Address - Country:US
Practice Address - Phone:719-539-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
COACB.0008406101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)