Provider Demographics
NPI:1619921798
Name:BLALACK, JASON (LAC, MS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BLALACK
Suffix:
Gender:M
Credentials:LAC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 30TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 30TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1200
Practice Address - Country:US
Practice Address - Phone:303-545-5792
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO864171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist