Provider Demographics
NPI:1336789262
Name:CROFT, WILLIAM JAKE (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JAKE
Last Name:CROFT
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 1:4563 BORING POND RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31606-1947
Mailing Address - Country:US
Mailing Address - Phone:229-834-9366
Mailing Address - Fax:
Practice Address - Street 1:603 N SAINT AUGUSTINE RD STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-3809
Practice Address - Country:US
Practice Address - Phone:229-834-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor