Provider Demographics
NPI:1750657482
Name:JAYWALKER LODGE, INC.
Entity Type:Organization
Organization Name:JAYWALKER LODGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-704-9292
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-0969
Mailing Address - Country:US
Mailing Address - Phone:970-704-9292
Mailing Address - Fax:
Practice Address - Street 1:35 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-1901
Practice Address - Country:US
Practice Address - Phone:970-704-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1548-01324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility