Provider Demographics
NPI:1639419294
Name:VEZZOSO, JAYSON (MT)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:VEZZOSO
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-9517
Mailing Address - Country:US
Mailing Address - Phone:970-948-7651
Mailing Address - Fax:
Practice Address - Street 1:564 HIGHWAY 133
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-1645
Practice Address - Country:US
Practice Address - Phone:970-963-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist