Provider Demographics
NPI:1790700896
Name:SHIRLEY, JEFFREY LEON (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEON
Last Name:SHIRLEY
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 1:4015 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75226-1231
Mailing Address - Country:US
Mailing Address - Phone:469-334-0624
Mailing Address - Fax:214-269-7547
Practice Address - Street 1:4015 MAIN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-1231
Practice Address - Country:US
Practice Address - Phone:469-334-0624
Practice Address - Fax:214-269-7547
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4994111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC06054835Medicaid
TX605483Medicare ID - Type Unspecified
TXC06054835Medicaid