Healthcare Provider Details

I. General information

NPI: 1366926065
Provider Name (Legal Business Name): JEREMY JAMES KUJAWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E PEAKVIEW AVE
CENTENNIAL CO
80121-3539
US

IV. Provider business mailing address

25117 SW PARKWAY AVE STE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 303-713-4486
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number0014413
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: