Provider Demographics
NPI:1295273746
Name:ALBERT, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:ALBERT
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 1:36 CANYON VIEW RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-9634
Mailing Address - Country:US
Mailing Address - Phone:303-530-2190
Mailing Address - Fax:303-530-2190
Practice Address - Street 1:36 CANYON VIEW RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-9634
Practice Address - Country:US
Practice Address - Phone:303-530-2190
Practice Address - Fax:303-530-2190
Is Sole Proprietor?:No
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO19268171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04141198Medicaid