Provider Demographics
NPI:1043457252
Name:DUBOIS, JASON RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RICHARD
Last Name:DUBOIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 9TH ST
Mailing Address - Street 2:STE 1
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-2207
Mailing Address - Country:US
Mailing Address - Phone:208-436-4100
Mailing Address - Fax:208-678-4101
Practice Address - Street 1:1218 9TH ST
Practice Address - Street 2:STE 1
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-2207
Practice Address - Country:US
Practice Address - Phone:208-436-4100
Practice Address - Fax:208-678-4101
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808252700Medicaid
ID1678905Medicare PIN