=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558667287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAX BAX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2011
-----------------------------------------------------
Last Update Date | 06/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7426 STATE ROAD 21
-----------------------------------------------------
City | KEYSTONE HEIGHTS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32656-7840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-257-5595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7426 STATE ROAD 21
-----------------------------------------------------
City | KEYSTONE HEIGHTS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32656-7840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-257-5595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. NANCY SHORT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 904-257-5595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9732
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------