Provider Demographics
NPI:1912187006
Name:GOODRUM, JEREMY LYN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LYN
Last Name:GOODRUM
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 1:306 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-3923
Mailing Address - Country:US
Mailing Address - Phone:620-326-3611
Mailing Address - Fax:620-326-6939
Practice Address - Street 1:306 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3923
Practice Address - Country:US
Practice Address - Phone:620-326-3611
Practice Address - Fax:620-326-6939
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05164111N00000X
KST-01655111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor