Provider Demographics
NPI:1588798003
Name:DONNELLY, JACK (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:DONNELLY
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 1:3811 TURTLE CREEK BLVD
Mailing Address - Street 2:STE. 315
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4402
Mailing Address - Country:US
Mailing Address - Phone:214-357-9119
Mailing Address - Fax:214-357-4494
Practice Address - Street 1:3811 TURTLE CREEK BLVD
Practice Address - Street 2:STE. 315
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4402
Practice Address - Country:US
Practice Address - Phone:214-357-9119
Practice Address - Fax:214-357-4494
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609250Medicare UPIN