Provider Demographics
NPI:1548215320
Name:PETTIS, JAY L (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:L
Last Name:PETTIS
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 1:1570 CENTURY POINT
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121
Mailing Address - Country:US
Mailing Address - Phone:651-405-3990
Mailing Address - Fax:651-405-6627
Practice Address - Street 1:1570 CENTURY POINT
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121
Practice Address - Country:US
Practice Address - Phone:651-405-3990
Practice Address - Fax:651-405-6627
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
534G2PEOtherBCBS
534G2PEOtherBCBS