Provider Demographics
NPI:1952448169
Name:BRAITHWAITE, JASON (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BRAITHWAITE
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 1:5005 43RD AVE
Mailing Address - Street 2:APT. 2A
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4471
Mailing Address - Country:US
Mailing Address - Phone:646-468-3325
Mailing Address - Fax:
Practice Address - Street 1:10 PARK AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4338
Practice Address - Country:US
Practice Address - Phone:646-468-3325
Practice Address - Fax:212-918-9306
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX9C351Medicare ID - Type Unspecified