Basic Information
Provider Information | |||||||||
NPI: | 1326129461 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | JARED | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O., PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4900 S MONACO ST STE 210 | ||||||||
Address2: |   | ||||||||
City: | DENVER | ||||||||
State: | CO | ||||||||
PostalCode: | 802373487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034532997 | ||||||||
FaxNumber: | 3034532998 | ||||||||
Practice Location | |||||||||
Address1: | 9195 GRANT ST STE 120 | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802294386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034532997 | ||||||||
FaxNumber: | 3034532998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 10/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5101018188 | MI | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 34.011200 | OH | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 363AM0700X | 008895-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207X00000X | DR.0055441 | CO | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 10223517 | 05 | CO |   | MEDICAID |