=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639060049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY C. PEDERSEN, D.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2025
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2920 W PARK ROW DR STE 100
-----------------------------------------------------
City | PANTEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-277-1111
-----------------------------------------------------
Fax | 817-861-4593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2920 W PARK ROW DR STE 100
-----------------------------------------------------
City | PANTEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-277-1111
-----------------------------------------------------
Fax | 817-861-4593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ALLISON PEDERSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-277-1111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------