Provider Demographics
NPI:1700109923
Name:VICKERY, JORDAN WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:WADE
Last Name:VICKERY
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 1:1000 ZSCHOKKE ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1650
Mailing Address - Country:US
Mailing Address - Phone:618-654-4451
Mailing Address - Fax:618-654-1567
Practice Address - Street 1:12860 TROXLER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2898
Practice Address - Country:US
Practice Address - Phone:618-654-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4535001Medicare PIN