Provider Demographics
NPI:1174153738
Name:CROCKETT SPINE & SPORT PLLC
Entity type:Organization
Organization Name:CROCKETT SPINE & SPORT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WHITBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:731-234-6208
Mailing Address - Street 1:70 PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-1403
Mailing Address - Country:US
Mailing Address - Phone:731-696-2525
Mailing Address - Fax:
Practice Address - Street 1:143 S BELLS ST
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001-1731
Practice Address - Country:US
Practice Address - Phone:731-696-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-23
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty