=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891010526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON WADE DIXON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2010
-----------------------------------------------------
Last Update Date | 01/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 PAUL BUNYAN DR NW
-----------------------------------------------------
City | BEMIDJI
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56601-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-751-5910
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 PAUL BUNYAN DR NW
-----------------------------------------------------
City | BEMIDJI
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56601-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-751-5910
-----------------------------------------------------
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 | 5309
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------