Provider Demographics
NPI:1417073826
Name:SHACKELFORD, JERRY BAXTER (D C)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BAXTER
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2501
Mailing Address - Country:US
Mailing Address - Phone:615-944-2305
Mailing Address - Fax:615-868-2596
Practice Address - Street 1:521 E CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2501
Practice Address - Country:US
Practice Address - Phone:615-944-2305
Practice Address - Fax:615-868-2596
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00179111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3671553Medicare ID - Type UnspecifiedPROVIDER NUMBER