Provider Demographics
NPI:1558302869
Name:JIMERSON, JEREMIAH J (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:J
Last Name:JIMERSON
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 1:113 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6007
Mailing Address - Country:US
Mailing Address - Phone:843-873-6004
Mailing Address - Fax:843-871-0400
Practice Address - Street 1:113 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6007
Practice Address - Country:US
Practice Address - Phone:843-873-6004
Practice Address - Fax:843-871-0400
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011070-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3131OtherLICENSE/CHIROPRACTOR
RA7035Medicare ID - Type Unspecified
VO5426Medicare UPIN