Provider Demographics
NPI:1891414835
Name:WALLJASPER, LUCAS BRYANT
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:BRYANT
Last Name:WALLJASPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2206
Mailing Address - Country:US
Mailing Address - Phone:414-559-6930
Mailing Address - Fax:
Practice Address - Street 1:3320 13TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2206
Practice Address - Country:US
Practice Address - Phone:414-559-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0020596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health