Provider Demographics
NPI:1558321638
Name:CROCKER, JACK D (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:CROCKER
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 1:464 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-2742
Mailing Address - Country:US
Mailing Address - Phone:417-532-9166
Mailing Address - Fax:417-532-9887
Practice Address - Street 1:464 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2742
Practice Address - Country:US
Practice Address - Phone:417-532-9166
Practice Address - Fax:417-532-9887
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42945Medicare UPIN
MO000030053Medicare PIN