Provider Demographics
NPI:1962509604
Name:THEOBALD, JASON C (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
Last Name:THEOBALD
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 1:550 W MAPLE ST
Mailing Address - Street 2:SUITE # 201
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1166
Mailing Address - Country:US
Mailing Address - Phone:608-355-4100
Mailing Address - Fax:608-355-4107
Practice Address - Street 1:550 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1166
Practice Address - Country:US
Practice Address - Phone:608-355-4100
Practice Address - Fax:608-355-4107
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3855-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38996600OtherMEDICAID GROUP
WICB3715OtherRAILROAD MEDICARE GROUP
WI38939100Medicaid
WI350056012OtherRAILROAD MEDICARE
U92024Medicare UPIN
WI350056012OtherRAILROAD MEDICARE