Provider Demographics
NPI:1629532734
Name:MOORE, JASON DEWITT (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DEWITT
Last Name:MOORE
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 1:2204 2ND AVE W STE 102
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3485
Mailing Address - Country:US
Mailing Address - Phone:701-577-7771
Mailing Address - Fax:
Practice Address - Street 1:2204 2ND AVE W STE 102
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3485
Practice Address - Country:US
Practice Address - Phone:701-577-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1087111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1087OtherCHIROPRACTIC STATE BOARD