Provider Demographics
NPI:1720282155
Name:MCCORMACK, JUTHARAT (LPC, RN, CAC III)
Entity Type:Individual
Prefix:MS
First Name:JUTHARAT
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:LPC, RN, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 STOUT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2941
Mailing Address - Country:US
Mailing Address - Phone:720-341-8694
Mailing Address - Fax:
Practice Address - Street 1:2610 STOUT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2941
Practice Address - Country:US
Practice Address - Phone:303-504-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO162465163W00000X
CO6391101YP2500X
CO7138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional