Provider Demographics
NPI:1578820247
Name:MANGUM, JARED D (DC, MBA, LMT)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:D
Last Name:MANGUM
Suffix:
Gender:M
Credentials:DC, MBA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8659 N RUDE ST
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8255
Mailing Address - Country:US
Mailing Address - Phone:801-762-7447
Mailing Address - Fax:
Practice Address - Street 1:8659 N RUDE ST
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8255
Practice Address - Country:US
Practice Address - Phone:801-762-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5266084-1202111N00000X
IDCHIA-2025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor