Provider Demographics
NPI:1932831815
Name:RUTMAN, JACKIE (ECSC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:RUTMAN
Suffix:
Gender:F
Credentials:ECSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 CHERRY CK S DR APT 4
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-4018
Mailing Address - Country:US
Mailing Address - Phone:720-226-3341
Mailing Address - Fax:
Practice Address - Street 1:9200 CHERRY CK S DR APT 4
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-4018
Practice Address - Country:US
Practice Address - Phone:720-226-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24390966222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist