Provider Demographics
NPI:1225186851
Name:CHRISTENSEN, JERRY ALLAN (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALLAN
Last Name:CHRISTENSEN
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 1:1000 N 1ST ST STE 1
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-6209
Mailing Address - Country:US
Mailing Address - Phone:815-758-1218
Mailing Address - Fax:815-758-2048
Practice Address - Street 1:1000 N 1ST ST STE 1
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-6209
Practice Address - Country:US
Practice Address - Phone:815-758-1218
Practice Address - Fax:815-758-2048
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008400111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
538560Medicare UPIN