Provider Demographics
NPI:1821075375
Name:CROCKETT, JASON MITCHELL (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MITCHELL
Last Name:CROCKETT
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 1:733 W KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1229
Mailing Address - Country:US
Mailing Address - Phone:417-831-7575
Mailing Address - Fax:417-831-7632
Practice Address - Street 1:733 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1229
Practice Address - Country:US
Practice Address - Phone:417-831-7575
Practice Address - Fax:417-831-7632
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001006863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1921532OtherFIRST HEALTH & CCN
MO4400576OtherUNITED HEALTHCARE
MO9168688OtherPRIVATE HEALTHCARE SYSTEM
MO466725OtherHEALTHLINK
MO7825256OtherAETNA
MOP00324028OtherRAILROAD MEDICARE
MO143164OtherBLUE CROSS BLUE SHIELD
MO755773900Medicaid
MO755773900Medicaid