Provider Demographics
NPI:1023230257
Name:JLA MEDICAL SERVICES
Entity type:Organization
Organization Name:JLA MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:LAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERRITSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-499-2217
Mailing Address - Street 1:1062 LOVE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2975
Mailing Address - Country:US
Mailing Address - Phone:303-499-2217
Mailing Address - Fax:
Practice Address - Street 1:255 CANYON BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4979
Practice Address - Country:US
Practice Address - Phone:303-449-7541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO180762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty