Provider Demographics
NPI:1891025979
Name:MCCLINTOCK, JASON DOUGLAS (LMT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DOUGLAS
Last Name:MCCLINTOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 DEER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-9418
Mailing Address - Country:US
Mailing Address - Phone:970-769-5320
Mailing Address - Fax:
Practice Address - Street 1:85 W. MILL STREET
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122
Practice Address - Country:US
Practice Address - Phone:970-769-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3592225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist