Provider Demographics
NPI:1760412365
Name:DAVIDSON, JASON HOWARD (DC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:HOWARD
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 FALLS RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-7702
Mailing Address - Country:US
Mailing Address - Phone:919-866-1985
Mailing Address - Fax:
Practice Address - Street 1:2609 DISCOVERY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-1905
Practice Address - Country:US
Practice Address - Phone:919-877-7448
Practice Address - Fax:919-875-8454
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908KKMedicaid
NC085KKOtherBCBCNC
NC647382OtherACN
NC085KKOtherBCBCNC