Provider Demographics
NPI:1871790832
Name:ANDERSON, JADEAN JAKE (DC)
Entity type:Individual
Prefix:
First Name:JADEAN
Middle Name:JAKE
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 1:4132 30TH AVE SOUTH
Mailing Address - Street 2:SUITE #102
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8407
Mailing Address - Country:US
Mailing Address - Phone:701-371-2298
Mailing Address - Fax:701-241-7738
Practice Address - Street 1:4132 30TH AVE SOUTH
Practice Address - Street 2:SUITE #102
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8407
Practice Address - Country:US
Practice Address - Phone:701-241-7737
Practice Address - Fax:701-241-7738
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND390200000X111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDAND28655OtherBLUE CROSS BLUE SHIELD ND
NDU712753Medicare UPIN
NDN712754Medicare PIN