Provider Demographics
NPI:1508007493
Name:LANE, GERALD JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:JACOB
Last Name:LANE
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 1:290 FERRY ST
Mailing Address - Street 2:A1
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3475
Mailing Address - Country:US
Mailing Address - Phone:973-344-5656
Mailing Address - Fax:973-344-5633
Practice Address - Street 1:290 FERRY ST
Practice Address - Street 2:A1
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3475
Practice Address - Country:US
Practice Address - Phone:973-344-5656
Practice Address - Fax:973-344-5633
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00671700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor