Provider Demographics
NPI:1578661872
Name:DAVENPORT, JEFFREY A (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:DAVENPORT
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 1:1031 PARK DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6060
Mailing Address - Country:US
Mailing Address - Phone:706-310-0575
Mailing Address - Fax:706-310-0576
Practice Address - Street 1:1031 PARK DR STE 4
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6060
Practice Address - Country:US
Practice Address - Phone:706-310-0575
Practice Address - Fax:706-310-0576
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALIC6636111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHBXMedicare PIN
GAU79874Medicare UPIN