Provider Demographics
NPI:1538132667
Name:HATLEY, JERRY PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:PAUL
Last Name:HATLEY
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 1:210 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4763
Mailing Address - Country:US
Mailing Address - Phone:972-708-9922
Mailing Address - Fax:
Practice Address - Street 1:210 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4763
Practice Address - Country:US
Practice Address - Phone:972-708-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX603588OtherMEDICARE PTAN
TXT95819Medicare UPIN
TX603588OtherMEDICARE PTAN