Provider Demographics
NPI:1750682621
Name:DAVIS, JACLYN A (LCSW)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-2002
Mailing Address - Country:US
Mailing Address - Phone:303-857-6365
Mailing Address - Fax:303-857-2123
Practice Address - Street 1:145 1ST ST
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-2002
Practice Address - Country:US
Practice Address - Phone:303-857-6365
Practice Address - Fax:303-857-2123
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7241101YA0400X
CO16541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)