Provider Demographics
NPI:1013217900
Name:DEBOODT, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DEBOODT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 W DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1486
Mailing Address - Country:US
Mailing Address - Phone:970-484-2843
Mailing Address - Fax:970-490-2774
Practice Address - Street 1:2160 W DRAKE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1486
Practice Address - Country:US
Practice Address - Phone:970-484-2843
Practice Address - Fax:970-490-2774
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist