Provider Demographics
NPI:1205412665
Name:NORTON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:NORTON
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 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2420
Mailing Address - Fax:970-267-7290
Practice Address - Street 1:1725 E BOULDER ST STE 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5740
Practice Address - Country:US
Practice Address - Phone:719-365-6300
Practice Address - Fax:719-365-6094
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13665363A00000X
COPA.0008412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN13665Medicaid