Provider Demographics
NPI:1821323957
Name:DORAN, JAC RANDALL
Entity Type:Individual
Prefix:
First Name:JAC
Middle Name:RANDALL
Last Name:DORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-5857
Mailing Address - Country:US
Mailing Address - Phone:417-838-1701
Mailing Address - Fax:
Practice Address - Street 1:1948 E CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7815
Practice Address - Country:US
Practice Address - Phone:417-551-3210
Practice Address - Fax:888-527-0428
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist