Provider Demographics
NPI:1306045315
Name:JLB,INC
Entity Type:Organization
Organization Name:JLB,INC
Other - Org Name:FONTANA FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:BRIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-325-7195
Mailing Address - Street 1:450 MILL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1242
Mailing Address - Country:US
Mailing Address - Phone:262-275-5005
Mailing Address - Fax:262-275-5004
Practice Address - Street 1:450 MILL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FONTANA
Practice Address - State:WI
Practice Address - Zip Code:53125-1242
Practice Address - Country:US
Practice Address - Phone:262-275-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4188-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000054027OtherMEDICARE
WI38966200Medicaid