Provider Demographics
NPI:1902864457
Name:BONNETTE, JARED ANDERSON (DC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:ANDERSON
Last Name:BONNETTE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 W MAIN STREET CT
Mailing Address - Street 2:SUITE 175
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-5600
Mailing Address - Country:US
Mailing Address - Phone:801-770-3275
Mailing Address - Fax:810-770-3300
Practice Address - Street 1:40 W MAIN STREET CT
Practice Address - Street 2:SUITE 175
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-5600
Practice Address - Country:US
Practice Address - Phone:801-770-3275
Practice Address - Fax:810-770-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6970420-1202111N00000X
CO5486111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU98424Medicare UPIN
CO520988Medicare ID - Type Unspecified