1508406851 NPI number — JAI PITRE LCSW

Table of content: JAI PITRE LCSW (NPI 1508406851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508406851 NPI number — JAI PITRE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITRE
Provider First Name:
JAI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508406851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 800022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-0022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-953-0104
Provider Business Mailing Address Fax Number:
303-765-6640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
265 TANGLEWOOD LANE
Provider Second Line Business Practice Location Address:
STE W-3
Provider Business Practice Location Address City Name:
SILVERTHORNE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80498-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-468-1003
Provider Business Practice Location Address Fax Number:
970-262-2196
Provider Enumeration Date:
01/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904011408 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CSW.09926502 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1861562472 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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