Provider Demographics
NPI:1114173143
Name:WAYLAND, JERED MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JERED
Middle Name:MICHAEL
Last Name:WAYLAND
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 1:1424 KURRE LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2254
Mailing Address - Country:US
Mailing Address - Phone:573-334-0100
Mailing Address - Fax:
Practice Address - Street 1:1424 KURRE LN
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2254
Practice Address - Country:US
Practice Address - Phone:573-334-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009003271111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor