Provider Demographics
NPI:1932271129
Name:RASKEY, JERRY (DC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:RASKEY
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 1:16625 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-6720
Mailing Address - Country:US
Mailing Address - Phone:951-674-6841
Mailing Address - Fax:951-674-6843
Practice Address - Street 1:16625 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-6720
Practice Address - Country:US
Practice Address - Phone:951-674-6841
Practice Address - Fax:951-674-6843
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU59903Medicare UPIN