Provider Demographics
NPI:1770696031
Name:LISSENDEN, JEFF W (DC)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:W
Last Name:LISSENDEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SE MAYNARD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511
Mailing Address - Country:US
Mailing Address - Phone:919-650-2700
Mailing Address - Fax:919-650-1267
Practice Address - Street 1:1320 SE MAYNARD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-650-2700
Practice Address - Fax:919-650-1267
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC609865OtherACN
NC085XHOtherBLUE CROSS BLUE SHIELD
NC2458647Medicare ID - Type Unspecified
VAT88816Medicare UPIN