Provider Demographics
NPI:1942253448
Name:REGISTER, JERRY WILLIAM (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WILLIAM
Last Name:REGISTER
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 1:1233 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0484
Mailing Address - Country:US
Mailing Address - Phone:386-755-4379
Mailing Address - Fax:386-755-4556
Practice Address - Street 1:1233 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0484
Practice Address - Country:US
Practice Address - Phone:386-755-4379
Practice Address - Fax:386-755-4556
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3629111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88597OtherBCBS PROVIDER #
FL88597OtherBCBS PROVIDER #