Healthcare Provider Details

I. General information

NPI: 1629566922
Provider Name (Legal Business Name): JADE ASHLEY WYATT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JADE ASHLEY FREEMAN

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 BRIARGATE PKWY
COLORADO SPRINGS CO
80920-7804
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 719-305-9400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021-01448
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11414337-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberDR.0073259
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: