Healthcare Provider Details

I. General information

NPI: 1346247921
Provider Name (Legal Business Name): THOMAS JACK HANSON DC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 5TH ST NW
BEMIDJI MN
56601-2976
US

IV. Provider business mailing address

702 5TH ST NW
BEMIDJI MN
56601-2976
US

V. Phone/Fax

Practice location:
  • Phone: 218-751-9533
  • Fax: 218-444-4759
Mailing address:
  • Phone: 218-751-9533
  • Fax: 218-444-4759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1307
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: