Provider Demographics
NPI:1609964956
Name:WADDELL, JIMMY M (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:M
Last Name:WADDELL
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 1:421 KELLER PKWY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2302
Mailing Address - Country:US
Mailing Address - Phone:817-431-8881
Mailing Address - Fax:817-431-8878
Practice Address - Street 1:421 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2302
Practice Address - Country:US
Practice Address - Phone:817-431-8881
Practice Address - Fax:817-431-8878
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU41999Medicare UPIN