Provider Demographics
NPI:1417972514
Name:JAMISON, NOLAN BRADLEY (DC)
Entity Type:Individual
Prefix:MR
First Name:NOLAN
Middle Name:BRADLEY
Last Name:JAMISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MR
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:JAMISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:671 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-552-2584
Mailing Address - Fax:208-529-3992
Practice Address - Street 1:671 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-552-2584
Practice Address - Fax:208-529-3992
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-467111N00000X
CADC15251111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU56601Medicare UPIN