Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC1415 | LA |
Y | 111NR0400X | Rehabilitation Chiropractor | 11031 | TX |
N | 111NS0005X | Chiropractic Sports Physician | 11031 | TX |
NPI | 1295896512 |
---|---|
Provider Name | Dr. Jason P Deroche |
First Address | San Antonio, TX 78258-4185 |
Second Address | San Antonio, TX 78258-4185 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 08/08/2013 |