Provider Demographics
NPI:1790794220
Name:JELACIC, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:JELACIC
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 1:5177 BLACK GORE DR
Mailing Address - Street 2:UNIT B1
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-5273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5177 BLACK GORE DR
Practice Address - Street 2:UNIT B1
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5273
Practice Address - Country:US
Practice Address - Phone:970-688-1433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C806462Medicare PIN