Provider Demographics
NPI:1497775126
Name:WILBURN, JED (DC)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:
Last Name:WILBURN
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 1:1556 HARTNELL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-2277
Mailing Address - Country:US
Mailing Address - Phone:530-241-0712
Mailing Address - Fax:530-222-5837
Practice Address - Street 1:1556 HARTNELL AVE STE D
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2277
Practice Address - Country:US
Practice Address - Phone:530-241-0712
Practice Address - Fax:530-222-5837
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28198111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0281980Medicaid
CADC0281980OtherBLUE SHIELD OF CA
CADC0281980Medicaid
CADC0281980Medicare ID - Type Unspecified