Provider Demographics
NPI:1275817090
Name:BARE, JILLIAN ELISEQ (PT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ELISEQ
Last Name:BARE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:ELISE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:837 E 17TH AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1469
Mailing Address - Country:US
Mailing Address - Phone:505-570-1278
Mailing Address - Fax:
Practice Address - Street 1:311 MAPLETON AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3979
Practice Address - Country:US
Practice Address - Phone:303-544-5758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist