Provider Demographics
NPI:1366445447
Name:GUEVARA, JERRY BRENT (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:BRENT
Last Name:GUEVARA
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 1:620 SOUTHPOINTE CT
Mailing Address - Street 2:STE 290
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3897
Mailing Address - Country:US
Mailing Address - Phone:719-344-8057
Mailing Address - Fax:719-344-8114
Practice Address - Street 1:620 SOUTHPOINTE CT
Practice Address - Street 2:STE 290
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3897
Practice Address - Country:US
Practice Address - Phone:719-344-8057
Practice Address - Fax:719-344-8114
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4937111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801231OtherMEDICARE
CO801231OtherMEDICARE