Provider Demographics
NPI:1730408444
Name:DOMENICK, JASON KEITH (DC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:KEITH
Last Name:DOMENICK
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 1:905 W KEEGANS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-3409
Mailing Address - Country:US
Mailing Address - Phone:812-663-7640
Mailing Address - Fax:812-662-6356
Practice Address - Street 1:905 W KEEGANS WAY
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-3409
Practice Address - Country:US
Practice Address - Phone:812-663-7640
Practice Address - Fax:812-662-6356
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4073111N00000X
PADC010243111N00000X
IN08002663A111N00000X
IN81000133A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor