Provider Demographics
NPI:1447460548
Name:FOUNTAIN, JEFF (DC)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 ALPINE AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3495
Mailing Address - Country:US
Mailing Address - Phone:303-818-5343
Mailing Address - Fax:
Practice Address - Street 1:1155 ALPINE AVE
Practice Address - Street 2:STE 230
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3495
Practice Address - Country:US
Practice Address - Phone:303-818-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COT04856Medicare UPIN
CO18023Medicare ID - Type Unspecified