Provider Demographics
NPI:1639227366
Name:PETTIBON, JON M (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:M
Last Name:PETTIBON
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 1:3837 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2138
Mailing Address - Country:US
Mailing Address - Phone:253-752-3501
Mailing Address - Fax:253-752-3504
Practice Address - Street 1:3837 S 12TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2138
Practice Address - Country:US
Practice Address - Phone:253-752-3501
Practice Address - Fax:253-752-3504
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT02774Medicare UPIN