Provider Demographics
NPI:1518368836
Name:ANDERSON, JESSE (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:ANDERSON
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 1:982 N TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-1202
Mailing Address - Country:US
Mailing Address - Phone:920-471-9449
Mailing Address - Fax:
Practice Address - Street 1:982 N TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-1202
Practice Address - Country:US
Practice Address - Phone:920-471-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5043 - 12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor