Provider Demographics
NPI:1609959568
Name:PEDERSEN, JACK E (D C)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-1609
Mailing Address - Country:US
Mailing Address - Phone:541-367-2105
Mailing Address - Fax:
Practice Address - Street 1:1235 MAIN ST
Practice Address - Street 2:
Practice Address - City:SWEET HOME
Practice Address - State:OR
Practice Address - Zip Code:97386-1609
Practice Address - Country:US
Practice Address - Phone:541-367-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1401111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor