Provider Demographics
NPI:1891836292
Name:FUNICELLO, JAYSON THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:THOMAS
Last Name:FUNICELLO
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 1:320 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-1319
Mailing Address - Country:US
Mailing Address - Phone:434-326-5761
Mailing Address - Fax:
Practice Address - Street 1:306 ENTERPRISE DR STE B
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2644
Practice Address - Country:US
Practice Address - Phone:434-385-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7447111N00000X
VA0104556527111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor