Healthcare Provider Details

I. General information

NPI: 1740662642
Provider Name (Legal Business Name): JASON ROSS IMMERTREU APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JASON ROSS KLAPSTEIN APRN, PMHNP-BC

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 VILLAGE DR
PAGOSA SPRINGS CO
81147-8368
US

IV. Provider business mailing address

PO BOX 1328
DURANGO CO
81302-1328
US

V. Phone/Fax

Practice location:
  • Phone: 970-264-2104
  • Fax: 970-264-2108
Mailing address:
  • Phone: 970-335-2238
  • Fax: 970-335-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0997363-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: