Provider Demographics
NPI:1083741144
Name:DIPPE, JERRY WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WILLIAM
Last Name:DIPPE
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 1:7765 BODEGA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-823-6406
Mailing Address - Fax:707-823-6408
Practice Address - Street 1:7765 BODEGA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-823-6406
Practice Address - Fax:707-823-6408
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC10776111N00000X
PADC001454L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ542232OtherBLUE SHIELD
CADC0107761Medicare PIN
CAZZZ542232OtherBLUE SHIELD