Provider Demographics
NPI:1841313053
Name:MASK, JERRY (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:MASK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:KIP
Other - Middle Name:
Other - Last Name:MASK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:7203 W INTERSTATE 40
Mailing Address - Street 2:STE B
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2645
Mailing Address - Country:US
Mailing Address - Phone:806-353-1104
Mailing Address - Fax:806-331-3876
Practice Address - Street 1:7203 W INTERSTATE 40
Practice Address - Street 2:STE B
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2645
Practice Address - Country:US
Practice Address - Phone:806-353-1104
Practice Address - Fax:806-331-3876
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9281111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU91232Medicare UPIN
TX00935FMedicare ID - Type Unspecified