Provider Demographics
NPI:1740703503
Name:CLARKE, JEREMIAH GORDON (DC)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:GORDON
Last Name:CLARKE
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 1:5570 WILSON AVE SW STE L
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8867
Mailing Address - Country:US
Mailing Address - Phone:616-259-9835
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW STE L
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-259-9835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor