Healthcare Provider Details

I. General information

NPI: 1518145143
Provider Name (Legal Business Name): JASON ROBERT COLLISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 CORBETT DR
FORT COLLINS CO
80528-9579
US

IV. Provider business mailing address

4601 CORBETT DR
FORT COLLINS CO
80528-9579
US

V. Phone/Fax

Practice location:
  • Phone: 970-207-4857
  • Fax: 970-207-4885
Mailing address:
  • Phone: 970-207-4857
  • Fax: 970-207-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.095938
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number57013048
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8687A
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDR.0058484
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: