Provider Demographics
NPI:1588660005
Name:MCCLANE, JERRY D (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:D
Last Name:MCCLANE
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 1:3060 W COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-9347
Mailing Address - Country:US
Mailing Address - Phone:181-078-5072
Mailing Address - Fax:181-078-9367
Practice Address - Street 1:3060 W COLDWATER RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-9347
Practice Address - Country:US
Practice Address - Phone:181-078-5072
Practice Address - Fax:181-078-9367
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MI2301002158111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB55019Medicare ID - Type Unspecified
MIT82888Medicare UPIN