MEDICARE: DR. JONATHAN SWANSON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5128	WI

General Provider Information

NPI Number	:	1063885168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN SWANSON D.C.

Provider Business Mailing Address
First Line	:	1804 S ASHLAND AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-3702
Country	:	US
Telephone Number	:	920-432-7774
Fax Number	:	920-432-7784

Provider Business Practice Location Address
First Line	:	1804 S ASHLAND AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-3702
Country	:	US
Telephone Number	:	920-432-7774
Fax Number	:	920-432-7784

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2015
Last Update Date	:	11/11/2015

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