Provider Demographics
NPI:1013931070
Name:AMUNDSEN, JON ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ROBERT
Last Name:AMUNDSEN
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 1:4016 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3440
Mailing Address - Country:US
Mailing Address - Phone:419-698-3556
Mailing Address - Fax:419-698-3725
Practice Address - Street 1:4016 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3440
Practice Address - Country:US
Practice Address - Phone:419-698-3556
Practice Address - Fax:419-698-3725
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197742Medicaid
OHAM4038181Medicare ID - Type Unspecified
OH2197742Medicaid