Provider Demographics
NPI:1811202443
Name:WILLOUGHBY, JASON CYRIL (PSYD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CYRIL
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 EUDORA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80207-2500
Mailing Address - Country:US
Mailing Address - Phone:303-300-6333
Mailing Address - Fax:
Practice Address - Street 1:3401 EUDORA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80207-2500
Practice Address - Country:US
Practice Address - Phone:303-300-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0003944103TC0700X, 103TC2200X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84281375Medicaid
CO320557YLUMMedicare UPIN