Provider Demographics
NPI:1912158478
Name:LIVERGOOD, JAN (LAC)
Entity type:Individual
Prefix:MISS
First Name:JAN
Middle Name:
Last Name:LIVERGOOD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3676
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-3676
Mailing Address - Country:US
Mailing Address - Phone:970-390-7163
Mailing Address - Fax:
Practice Address - Street 1:1000 LIONS RIDGE LOOP
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-4412
Practice Address - Country:US
Practice Address - Phone:970-390-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO890171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist