Provider Demographics
NPI:1407935695
Name:CARTER, JERRY E (DC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:E
Last Name:CARTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1605 W CANDLETREE DRIVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-0486
Mailing Address - Fax:309-683-1113
Practice Address - Street 1:1605 W CANDLETREE DRIVE
Practice Address - Street 2:SUITE 111
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-0486
Practice Address - Fax:309-683-1113
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
660440Medicare UPIN