=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164680963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED JACK LAWSON D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2008
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 OAK ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-622-3330
-----------------------------------------------------
Fax | 207-622-3335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 OAK ST
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-622-3330
-----------------------------------------------------
Fax | 207-622-3335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CR1840
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------