Healthcare Provider Details

I. General information

NPI: 1073163150
Provider Name (Legal Business Name): JASON LAROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4856 INNOVATION DR
FORT COLLINS CO
80525-5539
US

IV. Provider business mailing address

4856 INNOVATION DR
FORT COLLINS CO
80525-5539
US

V. Phone/Fax

Practice location:
  • Phone: 970-494-4200
  • Fax: 844-270-1824
Mailing address:
  • Phone: 970-494-4200
  • Fax: 844-270-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACA.0008361
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: