Provider Demographics
NPI:1083791057
Name:SULLIVAN, JEFFREY ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALLEN
Last Name:SULLIVAN
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 1:294 TORBETT ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2664
Mailing Address - Country:US
Mailing Address - Phone:509-943-5533
Mailing Address - Fax:509-943-3155
Practice Address - Street 1:294 TORBETT ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2664
Practice Address - Country:US
Practice Address - Phone:509-943-5533
Practice Address - Fax:509-943-3155
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002853111N00000X
WA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA600-216-79OtherUNIFIED BUSINESS ID
WAAB35423Medicare ID - Type Unspecified
WAAB33206Medicare PIN
WA600-216-79OtherUNIFIED BUSINESS ID