Provider Demographics
NPI:1306988720
Name:JONASSON, KRISTAN WAYNE (DC)
Entity type:Individual
Prefix:
First Name:KRISTAN
Middle Name:WAYNE
Last Name:JONASSON
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:PO BOX 1184
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27361
Mailing Address - Country:US
Mailing Address - Phone:336-476-9600
Mailing Address - Fax:336-476-9636
Practice Address - Street 1:13 CLONIGER DR
Practice Address - Street 2:SUITE 5
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-5870
Practice Address - Country:US
Practice Address - Phone:336-476-9600
Practice Address - Fax:336-476-9636
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2712111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890840UMedicaid
NC0840UOtherBLUE CROSS BLUE SHIELD
NC0840UOtherBLUE CROSS BLUE SHIELD
NC890840UMedicaid