Provider Demographics
NPI:1912199910
Name:DETTWILER, JASON DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DAVID
Last Name:DETTWILER
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 1:1100 4 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-7397
Mailing Address - Country:US
Mailing Address - Phone:616-301-2225
Mailing Address - Fax:616-719-4593
Practice Address - Street 1:1100 4 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-7397
Practice Address - Country:US
Practice Address - Phone:616-301-2225
Practice Address - Fax:616-719-4593
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
35ZCGHZMedicare PIN
U81298Medicare UPIN