Healthcare Provider Details

I. General information

NPI: 1487250379
Provider Name (Legal Business Name): JARED LANE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 S BROADWAY STE 801
EDMOND OK
73013-4129
US

IV. Provider business mailing address

157 STONEBRIDGE BLVD APT 2232
EDMOND OK
73013-4775
US

V. Phone/Fax

Practice location:
  • Phone: 405-515-9355
  • Fax:
Mailing address:
  • Phone: 903-724-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4303
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: