Provider Demographics
NPI:1275712267
Name:JACK A PEDERSEN HURST CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:JACK A PEDERSEN HURST CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-251-7328
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80K571OtherBLUE CROSS INDIVIDUAL ID
TX00F40YOtherBLUE CROSS GROUP ID
TX1164484895OtherINDIVIDUAL NPI #
TX00F40YOtherBLUE CROSS GROUP ID
TX80K571OtherBLUE CROSS INDIVIDUAL ID