Healthcare Provider Details

I. General information

NPI: 1790749778
Provider Name (Legal Business Name): JAYDENE MASON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OAKSHIRE LN
PUEBLO CO
81001-5671
US

IV. Provider business mailing address

622 BELLEVIEW AVE
LA JUNTA CO
81050-2334
US

V. Phone/Fax

Practice location:
  • Phone: 719-295-7260
  • Fax: 719-295-7267
Mailing address:
  • Phone: 719-384-0184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number72274
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: