Provider Demographics
NPI:1861663346
Name:DAWSON, JEROD T (DC)
Entity type:Individual
Prefix:
First Name:JEROD
Middle Name:T
Last Name:DAWSON
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 1:1907 BOISE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-5016
Mailing Address - Country:US
Mailing Address - Phone:907-663-2200
Mailing Address - Fax:907-663-2201
Practice Address - Street 1:1907 BOISE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-5016
Practice Address - Country:US
Practice Address - Phone:907-663-2200
Practice Address - Fax:907-663-2201
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6194111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO400062OtherMEDICARE INDIVIDUAL PTAN