Provider Demographics
NPI:1083783971
Name:MUSTARD, JACK ALEXANDER (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALEXANDER
Last Name:MUSTARD
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 1:3501 SONCY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79121
Mailing Address - Country:US
Mailing Address - Phone:806-351-2708
Mailing Address - Fax:806-351-2349
Practice Address - Street 1:3501 SONCY
Practice Address - Street 2:SUITE 2
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79121
Practice Address - Country:US
Practice Address - Phone:806-351-2708
Practice Address - Fax:806-351-2349
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9759111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D1477OtherMEDICARE
TX608055OtherBLUE CROSS BLUE SHIELD
TX8D1477OtherMEDICARE