Provider Demographics
NPI:1255736146
Name:ELLER, JASON KIRK (DC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KIRK
Last Name:ELLER
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 1:423 NE 4TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2968
Mailing Address - Country:US
Mailing Address - Phone:218-326-8283
Mailing Address - Fax:218-326-8275
Practice Address - Street 1:423 NE 4TH ST STE 1
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2968
Practice Address - Country:US
Practice Address - Phone:218-326-8283
Practice Address - Fax:218-326-8275
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor