Provider Demographics
NPI:1356384879
Name:NEWSOME, JACK EDWARD JR (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDWARD
Last Name:NEWSOME
Suffix:JR
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 1:307 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:SC
Mailing Address - Zip Code:29657-1011
Mailing Address - Country:US
Mailing Address - Phone:864-506-1749
Mailing Address - Fax:
Practice Address - Street 1:21 S COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1132
Practice Address - Country:US
Practice Address - Phone:864-506-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7705111N00000X
SC2259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor