Provider Demographics
NPI:1164484895
Name:PEDERSEN, JACK A (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:PEDERSEN
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 1:7155 COLLEYVILLE BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-8003
Mailing Address - Country:US
Mailing Address - Phone:817-251-7328
Mailing Address - Fax:817-421-7380
Practice Address - Street 1:7155 COLLEYVILLE BLVD
Practice Address - Street 2:STE 103
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8003
Practice Address - Country:US
Practice Address - Phone:817-251-7328
Practice Address - Fax:817-421-7380
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15219Medicare UPIN
TX80K571Medicare ID - Type Unspecified