Provider Demographics
NPI:1396884581
Name:NANCE, JERRY CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:CHARLES
Last Name:NANCE
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:PO BOX 1726
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-0017
Mailing Address - Country:US
Mailing Address - Phone:254-965-6100
Mailing Address - Fax:254-965-1904
Practice Address - Street 1:140 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-4343
Practice Address - Country:US
Practice Address - Phone:254-965-6100
Practice Address - Fax:254-965-1904
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5104111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088400901Medicaid
TXU14210Medicare UPIN
TX603063Medicare ID - Type Unspecified