Healthcare Provider Details

I. General information

NPI: 1902864457
Provider Name (Legal Business Name): JARED ANDERSON BONNETTE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 W MAIN STREET CT SUITE 175
ALPINE UT
84004-5600
US

IV. Provider business mailing address

40 W MAIN STREET CT SUITE 175
ALPINE UT
84004-5600
US

V. Phone/Fax

Practice location:
  • Phone: 801-770-3275
  • Fax: 810-770-3300
Mailing address:
  • Phone: 801-770-3275
  • Fax: 810-770-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6970420-1202
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5486
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: