MEDICARE: JASON PATRICK GRISSOM MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	9081	CO

General Provider Information

NPI Number	:	1821015405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON PATRICK GRISSOM MPT

Provider Business Mailing Address
First Line	:	107 W 29TH ST
Second Line	:	STE 100
City	:	LOVELAND
State	:	CO
Zip	:	80538-2797
Country	:	US
Telephone Number	:	970-663-6142
Fax Number	:	970-635-3087

Provider Business Practice Location Address
First Line	:	3500 JOHN F KENNEDY PKWY STE 120
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2635
Country	:	US
Telephone Number	:	970-663-6142
Fax Number	:	970-635-3087

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/18/2019

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Directions to “ JASON PATRICK GRISSOM MPT” Practice Location

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