Provider Demographics
NPI:1336297779
Name:WISE, JON ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ALAN
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:91 SAMMY MCGHEE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-7703
Mailing Address - Country:US
Mailing Address - Phone:706-253-9355
Mailing Address - Fax:706-253-9352
Practice Address - Street 1:91 SAMMY MCGHEE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-7703
Practice Address - Country:US
Practice Address - Phone:706-253-9355
Practice Address - Fax:706-253-9352
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA6562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHTKMedicare PIN
GAU91130Medicare UPIN