Provider Demographics
NPI:1619237997
Name:MIRANOV, JASON BRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BRENT
Last Name:MIRANOV
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 1:4860 MANZANA DR APT 208
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-3008
Mailing Address - Country:US
Mailing Address - Phone:405-388-7864
Mailing Address - Fax:
Practice Address - Street 1:224 E WILLAMETTE AVE STE 5
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1114
Practice Address - Country:US
Practice Address - Phone:405-388-7864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor