Provider Demographics
NPI:1770931545
Name:JWAD, JUSTIN ISSAM (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ISSAM
Last Name:JWAD
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 1:5378 W DOHERTY ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2708
Mailing Address - Country:US
Mailing Address - Phone:248-885-1581
Mailing Address - Fax:
Practice Address - Street 1:5378 W DOHERTY ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2708
Practice Address - Country:US
Practice Address - Phone:248-885-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010442111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor