Provider Demographics
NPI:1366503831
Name:NIELSEN, JARED R (DC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:R
Last Name:NIELSEN
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 1:841 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1634
Mailing Address - Country:US
Mailing Address - Phone:541-476-3779
Mailing Address - Fax:541-476-3789
Practice Address - Street 1:1755 PROSPECTOR AVE STE 100
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7488
Practice Address - Country:US
Practice Address - Phone:435-649-6620
Practice Address - Fax:435-214-2236
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-3386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR131859Medicare PIN
ORU-91764Medicare UPIN
ORR131858Medicare ID - Type UnspecifiedGRP #