Healthcare Provider Details

I. General information

NPI: 1679949416
Provider Name (Legal Business Name): MICHELLE LAPORTE JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 MONROE AVE
LOVELAND CO
80538-3274
US

IV. Provider business mailing address

2930 11TH AVE
EVANS CO
80620-1011
US

V. Phone/Fax

Practice location:
  • Phone: 970-613-6800
  • Fax: 970-613-6801
Mailing address:
  • Phone: 970-350-4606
  • Fax: 970-350-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0007793
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: