Provider Demographics
NPI:1528172608
Name:EBNER, JACK ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALAN
Last Name:EBNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:1650 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6253
Practice Address - Country:US
Practice Address - Phone:562-799-2423
Practice Address - Fax:562-431-4868
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC14012OtherCHIROPRACTIC LICENSE
CADC0140120OtherBLUE SHIELD PIN