Provider Demographics
NPI:1619344256
Name:SAMPLE, JEREMIAH FREDERICK (DC, BS)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:FREDERICK
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:DC, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 S DALTON ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67210-1909
Mailing Address - Country:US
Mailing Address - Phone:316-214-0720
Mailing Address - Fax:
Practice Address - Street 1:2548 S DALTON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67210-1909
Practice Address - Country:US
Practice Address - Phone:316-214-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1856111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1856OtherNEBRASKA CHIROPRACTIC LICENSE NUMBER