Provider Demographics
NPI:1295816155
Name:WHEATLEY, JACK THURSTON (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:THURSTON
Last Name:WHEATLEY
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 1:840 W UNIVERSITY DR
Mailing Address - Street 2:#7
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5529
Mailing Address - Country:US
Mailing Address - Phone:480-964-1129
Mailing Address - Fax:480-649-4375
Practice Address - Street 1:840 W UNIVERSITY DR
Practice Address - Street 2:#7
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5529
Practice Address - Country:US
Practice Address - Phone:480-964-1129
Practice Address - Fax:480-649-4375
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor