Provider Demographics
NPI:1922208321
Name:FISK, JACOB WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WAYNE
Last Name:FISK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:241 N BUFFALO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0307
Mailing Address - Country:US
Mailing Address - Phone:702-852-1390
Mailing Address - Fax:702-577-3334
Practice Address - Street 1:241 N BUFFALO DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0307
Practice Address - Country:US
Practice Address - Phone:702-852-1390
Practice Address - Fax:702-577-3334
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01260111N00000X, 111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4107860727Medicare PIN