Provider Demographics
NPI:1114406352
Name:MONTOUR, JACOB (RBT-18-60502)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MONTOUR
Suffix:
Gender:M
Credentials:RBT-18-60502
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18395 W 83RD DR
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80007-7193
Mailing Address - Country:US
Mailing Address - Phone:720-483-4769
Mailing Address - Fax:
Practice Address - Street 1:18395 W 83RD DR
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-7193
Practice Address - Country:US
Practice Address - Phone:720-483-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18-60502106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician