Provider Demographics
NPI:1568732360
Name:DESTRO, JARED J (DC, ATC)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:J
Last Name:DESTRO
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11936A CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1701
Mailing Address - Country:US
Mailing Address - Phone:804-748-4800
Mailing Address - Fax:
Practice Address - Street 1:11936A CENTRE ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1701
Practice Address - Country:US
Practice Address - Phone:804-748-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor