Provider Demographics
NPI:1740662642
Name:IMMERTREU, JASON ROSS (APN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ROSS
Last Name:IMMERTREU
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:ROSS
Other - Last Name:KLAPSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, PMHNP-BC
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-335-2238
Mailing Address - Fax:970-335-2438
Practice Address - Street 1:52 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8368
Practice Address - Country:US
Practice Address - Phone:970-264-2104
Practice Address - Fax:970-264-2108
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997363-NP363LP0808X
IL041394399163W00000X
CA95009607363LP0808X
IL209012829363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse