=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790924892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON WOLSTENHOLME D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2009
-----------------------------------------------------
Last Update Date | 08/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 PINE ST STE G01
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-497-1002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 PINE ST STE G01
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-497-1002
-----------------------------------------------------
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 | 006.0056369
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------