Provider Demographics
NPI:1639161516
Name:PEDERSEN, JEFFREY CARL (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CARL
Last Name:PEDERSEN
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 1:2920 W PARK ROW DR
Mailing Address - Street 2:#100
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-2041
Mailing Address - Country:US
Mailing Address - Phone:817-277-1111
Mailing Address - Fax:817-861-4593
Practice Address - Street 1:2920 W PARK ROW DR
Practice Address - Street 2:#100
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-2041
Practice Address - Country:US
Practice Address - Phone:817-277-1111
Practice Address - Fax:817-861-4593
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15220Medicare UPIN
TX601477Medicare ID - Type Unspecified