MEDICARE: NORTHERN COLORADO PSYCHIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1942835897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN COLORADO PSYCHIATRY LLC

Provider Business Mailing Address
First Line	:	PO BOX 271215
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80527-1215
Country	:	US
Telephone Number	:	614-439-0053
Fax Number	:

Provider Business Practice Location Address
First Line	:	4786 MCMURRY AVE UNIT 2B
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4499
Country	:	US
Telephone Number	:	614-439-0053
Fax Number	:

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	DR. JASON ROBERT COLLISON
Credential	:	MD
Telephone Number	:	614-439-0053

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	03/10/2020

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