Provider Demographics
NPI:1033400585
Name:GARY, JAKE M (DC)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:M
Last Name:GARY
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 1:1833 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4045
Mailing Address - Country:US
Mailing Address - Phone:337-367-7463
Mailing Address - Fax:337-367-7461
Practice Address - Street 1:1833 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4045
Practice Address - Country:US
Practice Address - Phone:337-367-7463
Practice Address - Fax:337-367-7461
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor