Provider Demographics
NPI:1376636605
Name:POPP, JEREMY K (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:K
Last Name:POPP
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 1:1902 LOGANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9324
Mailing Address - Country:US
Mailing Address - Phone:219-808-5475
Mailing Address - Fax:219-509-3370
Practice Address - Street 1:634 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:IN
Practice Address - Zip Code:46341-9205
Practice Address - Country:US
Practice Address - Phone:219-509-3284
Practice Address - Fax:219-509-3370
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002588A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01626928OtherBLUE CROSS BLUE SHIELD IL
IL928670Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER