Provider Demographics
NPI:1275614679
Name:FISHER, JODY WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:WAYNE
Last Name:FISHER
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 1:142 MACCORKLE AVE
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-722-3011
Mailing Address - Fax:304-722-3045
Practice Address - Street 1:142 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177
Practice Address - Country:US
Practice Address - Phone:304-722-3011
Practice Address - Fax:304-722-3045
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FI41C0131Medicare ID - Type Unspecified
V05316Medicare UPIN