Provider Demographics
NPI:1558342154
Name:WEAVER, JACK DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DAVID
Last Name:WEAVER
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:PO BOX 492725
Mailing Address - Street 2:3051 VICTOR AVENUE
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002
Mailing Address - Country:US
Mailing Address - Phone:530-223-0583
Mailing Address - Fax:530-223-6316
Practice Address - Street 1:3051 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1450
Practice Address - Country:US
Practice Address - Phone:530-223-0583
Practice Address - Fax:530-223-6316
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC10695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T04020Medicare UPIN
DC0106950Medicare ID - Type Unspecified