Provider Demographics
NPI:1548523111
Name:PUDENZ, JASON MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:PUDENZ
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 1:322 W 3RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2708
Mailing Address - Country:US
Mailing Address - Phone:712-775-2418
Mailing Address - Fax:712-775-2418
Practice Address - Street 1:322 W 3RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-2708
Practice Address - Country:US
Practice Address - Phone:712-775-2418
Practice Address - Fax:712-775-2418
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR-6882111N00000X
IA007596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor