Provider Demographics
NPI:1679921902
Name:DAVIDSON, JAKE WESTLEY (DC)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:WESTLEY
Last Name:DAVIDSON
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 1:13831 RUSSELL ST APT 126
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7951 W 160TH STREET
Practice Address - Street 2:SUITE 500
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223
Practice Address - Country:US
Practice Address - Phone:731-414-3241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05879111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor