Provider Demographics
NPI:1639537038
Name:ZIMMER, JEFFRY SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:SHANE
Last Name:ZIMMER
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 1:143 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-2020
Mailing Address - Country:US
Mailing Address - Phone:401-521-1900
Mailing Address - Fax:
Practice Address - Street 1:143 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-2020
Practice Address - Country:US
Practice Address - Phone:401-521-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDCP00643111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor