Provider Demographics
NPI:1053798058
Name:BAKER, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BAKER
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 1:12865 W ALAMEDA DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2826
Mailing Address - Country:US
Mailing Address - Phone:720-670-6888
Mailing Address - Fax:
Practice Address - Street 1:441 WADSWORTH BLVD STE 105A
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-1545
Practice Address - Country:US
Practice Address - Phone:720-670-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0012979225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMT.0012979OtherMASSAGE LICENCE