Provider Demographics
NPI:1043450653
Name:LI, JACK THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:THOMAS
Last Name:LI
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 1:12340 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2500
Mailing Address - Country:US
Mailing Address - Phone:310-207-1007
Mailing Address - Fax:
Practice Address - Street 1:12340 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2500
Practice Address - Country:US
Practice Address - Phone:310-207-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 31142111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor