Provider Demographics
NPI:1649610056
Name:MACK, JADIAN STARLA (DC)
Entity type:Individual
Prefix:DR
First Name:JADIAN
Middle Name:STARLA
Last Name:MACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 S BROADWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-5933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1418 S BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-5933
Practice Address - Country:US
Practice Address - Phone:701-209-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND949111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor