Provider Demographics
NPI:1700921855
Name:FRY, JEFFERY ADAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:ADAM
Last Name:FRY
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 1:4800 JACKSON AVE SE
Mailing Address - Street 2:STE 104
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-1109
Mailing Address - Country:US
Mailing Address - Phone:360-876-4120
Mailing Address - Fax:360-876-4120
Practice Address - Street 1:4800 JACKSON AVE SE
Practice Address - Street 2:STE 104
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-1109
Practice Address - Country:US
Practice Address - Phone:360-876-4120
Practice Address - Fax:360-876-4120
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB04550Medicare ID - Type Unspecified
WAU48492Medicare UPIN