Provider Demographics
NPI:1497050959
Name:GARDNER, JACOB ROSS (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ROSS
Last Name:GARDNER
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 1:102 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:KS
Mailing Address - Zip Code:67455-2004
Mailing Address - Country:US
Mailing Address - Phone:785-524-4371
Mailing Address - Fax:785-524-4375
Practice Address - Street 1:102 E ELM ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:KS
Practice Address - Zip Code:67455-2004
Practice Address - Country:US
Practice Address - Phone:785-524-4371
Practice Address - Fax:785-524-4375
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-02850111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner