Provider Demographics
NPI:1629493580
Name:BALLWEG, JASON M (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:BALLWEG
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 1:3070 FISH HATCHERY RD
Mailing Address - Street 2:STE 2
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3187
Mailing Address - Country:US
Mailing Address - Phone:608-274-1945
Mailing Address - Fax:
Practice Address - Street 1:1633 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1839
Practice Address - Country:US
Practice Address - Phone:608-837-7712
Practice Address - Fax:608-825-6638
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor