Provider Demographics
NPI:1679628309
Name:WALLIN, JASON OWEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:OWEN
Last Name:WALLIN
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 1:4717 HIAWATHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3928
Mailing Address - Country:US
Mailing Address - Phone:612-721-2146
Mailing Address - Fax:
Practice Address - Street 1:4717 HIAWATHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3928
Practice Address - Country:US
Practice Address - Phone:612-721-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3838111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55F56BLOtherBCBS