Provider Demographics
NPI:1104043421
Name:CODY, JONATHAN P (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:CODY
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 1:421 WATER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2108
Mailing Address - Country:US
Mailing Address - Phone:608-643-5060
Mailing Address - Fax:608-643-5080
Practice Address - Street 1:421 WATER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2108
Practice Address - Country:US
Practice Address - Phone:608-643-5060
Practice Address - Fax:608-643-5080
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4031-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38954600Medicaid