Provider Demographics
NPI:1053482885
Name:WEST, JACK D (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:WEST
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:PO BOX 1352
Mailing Address - Street 2:154 14 ST
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-1352
Mailing Address - Country:US
Mailing Address - Phone:406-297-2811
Mailing Address - Fax:
Practice Address - Street 1:198 14 ST E
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-1352
Practice Address - Country:US
Practice Address - Phone:406-297-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0160327Medicaid
MT000004340Medicare ID - Type Unspecified