Basic Information
| Provider Information | |||||||||
| NPI: | 1104106053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALE | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5365 SPINE RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035309325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5365 SPINE RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035309325 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | UO2792 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 207N00000X | DR.0054751 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | DR.0054751 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
No ID Information.