Provider Demographics
NPI:1396374906
Name:JADE RECOVERY
Entity type:Organization
Organization Name:JADE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MFTC, LPCC
Authorized Official - Phone:833-523-3669
Mailing Address - Street 1:1480 S DEPEW ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-5860
Mailing Address - Country:US
Mailing Address - Phone:720-965-7219
Mailing Address - Fax:
Practice Address - Street 1:255 S ROUTT ST STE 265
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2271
Practice Address - Country:US
Practice Address - Phone:833-523-3669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1053957407Medicaid