Provider Demographics
NPI:1225045479
Name:VICTORINO, JONATHAN T (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:T
Last Name:VICTORINO
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 1:1867 AIRPORT WAY STE 140C
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4055
Mailing Address - Country:US
Mailing Address - Phone:907-455-7770
Mailing Address - Fax:907-451-7770
Practice Address - Street 1:1867 AIRPORT WAY STE 140C
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4055
Practice Address - Country:US
Practice Address - Phone:907-455-7770
Practice Address - Fax:907-451-7770
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK389111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH5926Medicaid