Provider Demographics
NPI:1366604506
Name:DOUGLASS, JEFFREY MADISON (ANP-BC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MADISON
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9766 KEENAN ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80130-8036
Mailing Address - Country:US
Mailing Address - Phone:646-318-6785
Mailing Address - Fax:
Practice Address - Street 1:2111 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2529
Practice Address - Country:US
Practice Address - Phone:303-312-2217
Practice Address - Fax:303-293-2309
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP01482363LA2200X
NMR67367363LA2200X
NY304819363LA2200X
COC-APN.0000199-C-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56236859Medicaid