Healthcare Provider Details

I. General information

NPI: 1457362816
Provider Name (Legal Business Name): JASON WEST DC NMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 CALL PL
POCATELLO ID
83201-3034
US

IV. Provider business mailing address

1185 CALL PLACE
POCATELLO ID
83201-2949
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-3216
  • Fax: 208-232-9412
Mailing address:
  • Phone: 208-232-3216
  • Fax: 208-232-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberCHIA940
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: