Provider Demographics
NPI:1295007326
Name:EJUWA, JERRYLEE OTIMEYE (DC)
Entity Type:Individual
Prefix:
First Name:JERRYLEE
Middle Name:OTIMEYE
Last Name:EJUWA
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 1:1025 S MAIN ST STE 305
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7506
Mailing Address - Country:US
Mailing Address - Phone:817-251-0550
Mailing Address - Fax:817-251-0599
Practice Address - Street 1:1025 S MAIN ST STE 305
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-7506
Practice Address - Country:US
Practice Address - Phone:817-251-0550
Practice Address - Fax:817-251-0599
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11959111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor