Provider Demographics
NPI:1225115223
Name:JACELONE, PETER (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:JACELONE
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 1:669 MILLBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3703
Mailing Address - Country:US
Mailing Address - Phone:973-895-5636
Mailing Address - Fax:
Practice Address - Street 1:669 MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-3703
Practice Address - Country:US
Practice Address - Phone:973-895-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00185400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ450465Medicare ID - Type Unspecified