Provider Demographics
NPI:1912908286
Name:COLEGROVE, JARRED RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JARRED
Middle Name:RYAN
Last Name:COLEGROVE
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 1:1335 JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1725
Mailing Address - Country:US
Mailing Address - Phone:770-535-0550
Mailing Address - Fax:770-535-1007
Practice Address - Street 1:1335 JUANITA AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1725
Practice Address - Country:US
Practice Address - Phone:770-535-0550
Practice Address - Fax:770-535-1007
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV812111N00000X
GACHIR007628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND2513506Medicaid
550785922005OtherBC BS
7668546OtherAETNA
8538660OtherCIGNA
WV550785922OtherWORKERS COMP
WV00812OtherHEALTHPLAN
WV3810000793Medicaid
WV550785922OtherWORKERS COMP
550785922005OtherBC BS