Provider Demographics
NPI:1154499184
Name:MAWER, JACK R (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:MAWER
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 1:681 ENCINITAS BLVD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3762
Mailing Address - Country:US
Mailing Address - Phone:760-753-3488
Mailing Address - Fax:760-753-3499
Practice Address - Street 1:681 ENCINITAS BLVD
Practice Address - Street 2:SUITE 312
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3762
Practice Address - Country:US
Practice Address - Phone:760-753-3488
Practice Address - Fax:760-753-3499
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25984Medicare UPIN
CAW17292Medicare ID - Type UnspecifiedGROUP ID #
CADC0259840Medicare UPIN
CADC25984Medicare ID - Type Unspecified