Provider Demographics
NPI:1710078431
Name:MCCULLOUGH, JASON CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:CHRISTOPHER
Last Name:MCCULLOUGH
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 1:2120 S 56TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-2118
Mailing Address - Country:US
Mailing Address - Phone:402-488-0288
Mailing Address - Fax:402-488-0289
Practice Address - Street 1:2120 S 56TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2118
Practice Address - Country:US
Practice Address - Phone:402-488-0288
Practice Address - Fax:402-488-0289
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025432300Medicaid
NE279902Medicare ID - Type Unspecified
NE10025432300Medicaid