Provider Demographics
NPI:1205852738
Name:FAGERSTROM, JEROME ALLAN (DC)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:ALLAN
Last Name:FAGERSTROM
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 1:654 BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6156
Mailing Address - Country:US
Mailing Address - Phone:608-362-7652
Mailing Address - Fax:608-362-7296
Practice Address - Street 1:654 BLUFF ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6156
Practice Address - Country:US
Practice Address - Phone:608-362-7652
Practice Address - Fax:608-362-7296
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3406111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38899100Medicaid
WI38899100Medicaid
WI000136000Medicare ID - Type Unspecified