Provider Demographics
NPI:1184916934
Name:SHORES, JONATHAN GRANT (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GRANT
Last Name:SHORES
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 1:3210 HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5022
Mailing Address - Country:US
Mailing Address - Phone:850-769-2220
Mailing Address - Fax:
Practice Address - Street 1:3210 HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5022
Practice Address - Country:US
Practice Address - Phone:850-769-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL220EMOtherBLUE CROSS BLUE SHIELD