Healthcare Provider Details

I. General information

NPI: 1255773982
Provider Name (Legal Business Name): JASON SUMMERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 TABLE MESA DR SUITE 203
BOULDER CO
80305-5869
US

IV. Provider business mailing address

3400 TABLE MESA DR SUITE 203
BOULDER CO
80305-5869
US

V. Phone/Fax

Practice location:
  • Phone: 303-499-9892
  • Fax:
Mailing address:
  • Phone: 303-499-9892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11363
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: