Provider Demographics
NPI:1619414422
Name:JACKSON, VELVET
Entity Type:Individual
Prefix:
First Name:VELVET
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 S CAMINO DEL RIO STE 102
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-6856
Mailing Address - Country:US
Mailing Address - Phone:970-828-3030
Mailing Address - Fax:970-247-0221
Practice Address - Street 1:450 S CAMINO DEL RIO STE 102
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-6856
Practice Address - Country:US
Practice Address - Phone:970-828-3030
Practice Address - Fax:970-247-0221
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1623855163W00000X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse