Provider Demographics
NPI:1881692770
Name:ANDERSON, JON MYREN (DC)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:MYREN
Last Name:ANDERSON
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 1:161 19TH ST S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2153
Mailing Address - Country:US
Mailing Address - Phone:320-253-0567
Mailing Address - Fax:320-253-9968
Practice Address - Street 1:161 19TH ST S
Practice Address - Street 2:SUITE 101
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2153
Practice Address - Country:US
Practice Address - Phone:320-253-0567
Practice Address - Fax:320-253-9968
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN512171100000X
MN3265111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP47389OtherHEALTH PARTNERS
MN39P49ANOtherBLUE CROSS BLUE SHEILD
MN283523100Medicaid