Provider Demographics
NPI:1689643736
Name:VONDRAK, JENNIFER FANCHON (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:FANCHON
Last Name:VONDRAK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BOYER ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:WALL LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51466
Mailing Address - Country:US
Mailing Address - Phone:712-664-2054
Mailing Address - Fax:712-664-2053
Practice Address - Street 1:102 BOYER ST.
Practice Address - Street 2:SUITE B
Practice Address - City:WALL LAKE
Practice Address - State:IA
Practice Address - Zip Code:51466
Practice Address - Country:US
Practice Address - Phone:712-664-2054
Practice Address - Fax:712-664-2053
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAO6224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1198671Medicaid
IA1198671Medicaid
IAA06224Medicare UPIN