Provider Demographics
NPI:1376803296
Name:BREITHAUPT, JEFFREY GLENN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GLENN
Last Name:BREITHAUPT
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 1:5091 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2325
Mailing Address - Country:US
Mailing Address - Phone:720-974-9477
Mailing Address - Fax:
Practice Address - Street 1:5091 KIPLING ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2325
Practice Address - Country:US
Practice Address - Phone:720-974-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor