Provider Demographics
NPI:1417421025
Name:JACKSON CREEK ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:JACKSON CREEK ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORETKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-238-3838
Mailing Address - Street 1:12136 W BAYAUD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2115
Mailing Address - Country:US
Mailing Address - Phone:303-238-3838
Mailing Address - Fax:303-987-0434
Practice Address - Street 1:16601 JACKSON CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132
Practice Address - Country:US
Practice Address - Phone:719-725-6060
Practice Address - Fax:303-987-0434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility