Provider Demographics
NPI:1043287352
Name:COATES, JACK JR (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:COATES
Suffix:JR
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 1:229 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-5721
Mailing Address - Country:US
Mailing Address - Phone:440-322-9096
Mailing Address - Fax:440-322-6710
Practice Address - Street 1:229 5TH ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-5721
Practice Address - Country:US
Practice Address - Phone:440-322-9096
Practice Address - Fax:440-322-6710
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34129330201OtherWORKER'S COMP
OH341293302026OtherCARESOURCE
OH000000129647OtherANTHEM BC/BS
OH341293302003OtherMEDICAL MUTUAL
OH350033709OtherRAILROAD MEDICARE
OH367277OtherWELLCARE
OH4332074OtherAETNA
OH10789858OtherCAQH
OH341293302001OtherMEDICAL MUTUAL
OH0405761Medicaid
OH1005721OtherASHN
OH0467451Medicare PIN
OH10789858OtherCAQH