Provider Demographics
NPI:1760668362
Name:HAYCOCK, JASON R (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:HAYCOCK
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:PO BOX 1194
Mailing Address - Street 2:
Mailing Address - City:LYMAN
Mailing Address - State:WY
Mailing Address - Zip Code:82937-1194
Mailing Address - Country:US
Mailing Address - Phone:307-787-6400
Mailing Address - Fax:
Practice Address - Street 1:225 W OWEN ST.
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:WY
Practice Address - Zip Code:82937
Practice Address - Country:US
Practice Address - Phone:307-787-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY611111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW9679Medicare PIN