Provider Demographics
NPI:1679902001
Name:HOLT, JASON KEITH
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:KEITH
Last Name:HOLT
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 1:1101 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3119
Mailing Address - Country:US
Mailing Address - Phone:719-468-2734
Mailing Address - Fax:719-456-0109
Practice Address - Street 1:30999 COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:LAS ANIMAS
Practice Address - State:CO
Practice Address - Zip Code:81054-9499
Practice Address - Country:US
Practice Address - Phone:719-662-1105
Practice Address - Fax:719-456-0109
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB.0007699171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator