Provider Demographics
NPI:1588190953
Name:FEARN, JACK (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:FEARN
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 1:2211 CORINTH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1650
Mailing Address - Country:US
Mailing Address - Phone:310-481-7160
Mailing Address - Fax:310-478-8521
Practice Address - Street 1:2211 CORINTH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1650
Practice Address - Country:US
Practice Address - Phone:310-481-7160
Practice Address - Fax:310-478-8521
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor