Provider Demographics
NPI:1033171038
Name:YADEN, JERALD G (DC)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:G
Last Name:YADEN
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 1:425 BARONY STREET
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461
Mailing Address - Country:US
Mailing Address - Phone:843-899-7933
Mailing Address - Fax:843-899-5796
Practice Address - Street 1:425 BARONY ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-899-7933
Practice Address - Fax:843-899-5796
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1432Medicaid
T05783Medicare UPIN