Provider Demographics
NPI:1366504797
Name:GILBERT, JERRY LEE (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:GILBERT
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 143
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49870-0143
Mailing Address - Country:US
Mailing Address - Phone:906-563-5871
Mailing Address - Fax:906-563-5969
Practice Address - Street 1:415 W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-1125
Practice Address - Country:US
Practice Address - Phone:906-563-5871
Practice Address - Fax:906-563-5969
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJG004627111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP29140001Medicare PIN