Provider Demographics
NPI:1720143837
Name:ALLOY, JACK M (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:ALLOY
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 1:632 SWAN DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-2882
Mailing Address - Country:US
Mailing Address - Phone:262-514-4470
Mailing Address - Fax:
Practice Address - Street 1:8320 W BLUEMOUND RD
Practice Address - Street 2:SUITE 125A
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3367
Practice Address - Country:US
Practice Address - Phone:414-302-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38947000Medicaid
WIU69849Medicare UPIN