Provider Demographics
NPI:1881101640
Name:JG LLC
Entity type:Organization
Organization Name:JG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:970-584-2100
Mailing Address - Street 1:2928 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5426
Mailing Address - Country:US
Mailing Address - Phone:970-584-2100
Mailing Address - Fax:970-584-2101
Practice Address - Street 1:2928 W 10TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-584-2100
Practice Address - Fax:970-584-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1881101640Medicaid