Provider Demographics
NPI:1417927427
Name:REISTER, JEREMY S (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:S
Last Name:REISTER
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 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:14050 FRUIT RIDGE AVE
Practice Address - Street 2:
Practice Address - City:KENT CITY
Practice Address - State:MI
Practice Address - Zip Code:49330-8922
Practice Address - Country:US
Practice Address - Phone:616-378-5538
Practice Address - Fax:616-399-4491
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009144111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11553234OtherCAQH
MI2301009144OtherLICENSE NUMBER
MI4873635Medicaid
MI0P28350Medicare ID - Type Unspecified
MI2301009144OtherLICENSE NUMBER