=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104383025
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB DYSON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2019
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 236TH ST NE STE 1
-----------------------------------------------------
City | NORTH LIBERTY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52317-9683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-213-0497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 236TH ST NE STE 1
-----------------------------------------------------
City | NORTH LIBERTY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52317-9683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-213-0497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 095459
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------