Provider Demographics
NPI:1356442651
Name:WILLES, JEFFREY B (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:WILLES
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 1:664 14TH STREET EAST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:NV
Mailing Address - Zip Code:89301
Mailing Address - Country:US
Mailing Address - Phone:775-289-6800
Mailing Address - Fax:775-289-2579
Practice Address - Street 1:664 14TH STREET EAST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301
Practice Address - Country:US
Practice Address - Phone:775-289-6800
Practice Address - Fax:775-289-2579
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV565B111N00000X
NV4182111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDC565BMedicare UPIN