Provider Demographics
NPI:1730138470
Name:JARVIS, KELLY B SR (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:B
Last Name:JARVIS
Suffix:SR
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 1:1150 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:HEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3938
Mailing Address - Country:US
Mailing Address - Phone:435-654-4468
Mailing Address - Fax:
Practice Address - Street 1:906 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2403
Practice Address - Country:US
Practice Address - Phone:435-654-3032
Practice Address - Fax:435-654-3035
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161157-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT48877Medicare UPIN