Provider Demographics
NPI:1407857915
Name:MARCIAL, JESUS (DC)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:
Last Name:MARCIAL
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 1:2200 W ENNIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-8054
Mailing Address - Country:US
Mailing Address - Phone:972-875-8676
Mailing Address - Fax:972-875-8481
Practice Address - Street 1:2200 W ENNIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-8054
Practice Address - Country:US
Practice Address - Phone:972-875-8676
Practice Address - Fax:972-875-8481
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9380653OtherPHCS PROVIDER ID
TX186463901Medicaid
TX608125OtherBLUE CROSS PROVIDER ID
TXV08429Medicare UPIN
TX9380653OtherPHCS PROVIDER ID