Provider Demographics
NPI:1891839395
Name:JINES, BRADFORD DWIGHT (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:DWIGHT
Last Name:JINES
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 1:424 HWY KK
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379
Mailing Address - Country:US
Mailing Address - Phone:636-462-3409
Mailing Address - Fax:636-462-3409
Practice Address - Street 1:424 HWY KK
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379
Practice Address - Country:US
Practice Address - Phone:636-462-3409
Practice Address - Fax:636-462-3409
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE005724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor