Provider Demographics
NPI:1982691911
Name:EVANS, JASON THOMAS (DC, DIBCN)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:THOMAS
Last Name:EVANS
Suffix:
Gender:M
Credentials:DC, DIBCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-0365
Mailing Address - Country:US
Mailing Address - Phone:605-256-0336
Mailing Address - Fax:605-256-0760
Practice Address - Street 1:732 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-3519
Practice Address - Country:US
Practice Address - Phone:605-256-0336
Practice Address - Fax:605-256-0760
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD868111NN0400X
SDSD868111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
No111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604360Medicaid
SD1619173523OtherGROUP NPI
SDDQ2901OtherGROUP PTAN
SD1982691911OtherINDIVIDUAL NPI
SD350055130OtherGROUP PTAN
SDS5421Medicare ID - Type UnspecifiedCHIROPRACTOR
SD7604360Medicaid
SD350055130Medicare PIN