MEDICARE: DR. JASON D HENRY DC, CCSP

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	980	SD
2	111NS0005X	Sports Physician Chiropractor	980	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20632	OTHER	SD	SIOUX VALLEY HEALTH PLAN
2	C980	OTHER	SD	DAKOTACARE
3	7594362	OTHER	SD	AETNA
4	6437	OTHER	SD	AVERA HEALTH PLANS
5	1594359	OTHER	SD	AMERICA'S PPO
6	4994635	OTHER	SD	BLUE CROSS

General Provider Information

NPI Number	:	1376529388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON D HENRY DC, CCSP

Provider Business Mailing Address
First Line	:	1727 S CLEVELAND AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-3245
Country	:	US
Telephone Number	:	605-334-6656
Fax Number	:	605-333-4875

Provider Business Practice Location Address
First Line	:	1727 S CLEVELAND AVE
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-3245
Country	:	US
Telephone Number	:	605-334-6656
Fax Number	:	605-333-4875

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	09/06/2012

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