Provider Demographics
NPI:1457054181
Name:BRANHAM, JASON GREGORY (DC, MA)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:GREGORY
Last Name:BRANHAM
Suffix:
Gender:M
Credentials:DC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 RIVERS BND S
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3836
Mailing Address - Country:US
Mailing Address - Phone:901-351-9703
Mailing Address - Fax:
Practice Address - Street 1:2901 RIVERS BND S
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-3836
Practice Address - Country:US
Practice Address - Phone:901-351-9703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOXXXXXXXXXXX111N00000X
MO0000000000000111NS0005X
MO171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician