Provider Demographics
NPI:1366037434
Name:JAX CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:JAX CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-874-3393
Mailing Address - Street 1:474 MARSH COVE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1837
Mailing Address - Country:US
Mailing Address - Phone:352-874-3393
Mailing Address - Fax:
Practice Address - Street 1:12086 FORT CAROLINE RD STE 302
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7639
Practice Address - Country:US
Practice Address - Phone:904-564-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty