Provider Demographics
NPI:1053332650
Name:WALL, JON T (DC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:T
Last Name:WALL
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 1:18669 INNSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:WI
Mailing Address - Zip Code:54648-7019
Mailing Address - Country:US
Mailing Address - Phone:608-269-0585
Mailing Address - Fax:
Practice Address - Street 1:116 PINE ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1336
Practice Address - Country:US
Practice Address - Phone:608-847-1888
Practice Address - Fax:608-847-1678
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2233-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38801200Medicaid
WI35361Medicare ID - Type UnspecifiedPROVIDER NUMBER