Healthcare Provider Details

I. General information

NPI: 1184191868
Provider Name (Legal Business Name): JESSICA BOTTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S PERRY ST STE 100
CASTLE ROCK CO
80104-1923
US

IV. Provider business mailing address

600 W COUNTY LINE RD APT 27-103
HIGHLANDS RANCH CO
80129-6534
US

V. Phone/Fax

Practice location:
  • Phone: 303-688-8989
  • Fax:
Mailing address:
  • Phone: 661-623-6594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0005613
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: