Provider Demographics
NPI:1790756500
Name:GARDNER, JASON ROSS (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ROSS
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
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Mailing Address - Street 1:2239 GEORGIA HIGHWAY 20 SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2091
Mailing Address - Country:US
Mailing Address - Phone:770-922-8150
Mailing Address - Fax:770-922-8151
Practice Address - Street 1:2239 GEORGIA HIGHWAY 20 SE
Practice Address - Street 2:SUITE D
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2091
Practice Address - Country:US
Practice Address - Phone:770-922-8150
Practice Address - Fax:770-922-8151
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-02-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GACHIR007480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJSXMedicare PIN