Provider Demographics
NPI:1366465007
Name:THORNTON, JEREMY DWAIN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DWAIN
Last Name:THORNTON
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:PO BOX 1028
Mailing Address - Street 2:205 SOUTH ST.
Mailing Address - City:STOCKTON
Mailing Address - State:MO
Mailing Address - Zip Code:65785-1028
Mailing Address - Country:US
Mailing Address - Phone:417-276-6306
Mailing Address - Fax:417-276-6216
Practice Address - Street 1:205 SOUTH ST.
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:MO
Practice Address - Zip Code:65785-1028
Practice Address - Country:US
Practice Address - Phone:417-276-6306
Practice Address - Fax:417-276-6216
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6617111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU70733Medicare UPIN