Basic Information
| Provider Information | |||||||||
| NPI: | 1811202443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLOUGHBY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | CYRIL | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 EUDORA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802072500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033006333 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 EUDORA ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802072500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033006333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY.0003944 | CO | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC2200X | PSY.0003944 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 84281375 | 05 | CO | MEDICAID |