Provider Demographics
NPI:1255493854
Name:FAUBION, JACK E (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:FAUBION
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 1:405 W BOXELDER RD
Mailing Address - Street 2:SUITE A1
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5320
Mailing Address - Country:US
Mailing Address - Phone:307-685-2225
Mailing Address - Fax:307-685-6436
Practice Address - Street 1:405 W BOXELDER RD
Practice Address - Street 2:SUITE A1
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5320
Practice Address - Country:US
Practice Address - Phone:307-685-2225
Practice Address - Fax:307-685-6436
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY602111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY311379OtherBLUE CROSS BLUE SHIELD
U89423Medicare UPIN
WY20698Medicare ID - Type Unspecified