Healthcare Provider Details

I. General information

NPI: 1376620831
Provider Name (Legal Business Name): BRIAN VANCE JONGEWARD DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 17TH AVE SOUTH SUITE C
GRAND FORKS ND
58201-4048
US

IV. Provider business mailing address

2812 17TH AVE S SUITE C
GRAND FORKS ND
58201-4048
US

V. Phone/Fax

Practice location:
  • Phone: 701-775-0223
  • Fax:
Mailing address:
  • Phone: 701-775-0223
  • Fax: 701-738-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number611
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number611
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: