Provider Demographics
NPI:1376620831
Name:JONGEWARD, BRIAN VANCE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:VANCE
Last Name:JONGEWARD
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 1:2812 17TH AVE S
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4048
Mailing Address - Country:US
Mailing Address - Phone:701-775-0223
Mailing Address - Fax:701-738-0655
Practice Address - Street 1:2812 17TH AVE SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4048
Practice Address - Country:US
Practice Address - Phone:701-775-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND611111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18728Medicaid
N70789Medicare ID - Type Unspecified
U59515Medicare UPIN