Provider Demographics
NPI:1255670949
Name:ACTIVE HEALTH CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ACTIVE HEALTH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:JESSOP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:901-340-1837
Mailing Address - Street 1:7844 FARMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2904
Mailing Address - Country:US
Mailing Address - Phone:901-340-1837
Mailing Address - Fax:
Practice Address - Street 1:7844 FARMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2904
Practice Address - Country:US
Practice Address - Phone:901-340-1837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2075111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty