Provider Demographics
NPI:1922755750
Name:STORTI, JACK (ACC0998204)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STORTI
Suffix:
Gender:M
Credentials:ACC0998204
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18425 PONY EXPRESS DR UNIT 203
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9605
Mailing Address - Country:US
Mailing Address - Phone:303-805-1218
Mailing Address - Fax:
Practice Address - Street 1:18425 PONY EXPRESS DR UNIT 203
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-9605
Practice Address - Country:US
Practice Address - Phone:303-805-1218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0998204101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)