Provider Demographics
NPI:1952438319
Name:ANDERSON, JAY PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:PATRICK
Last Name:ANDERSON
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:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-0254
Mailing Address - Country:US
Mailing Address - Phone:419-878-8312
Mailing Address - Fax:419-878-8844
Practice Address - Street 1:751 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1052
Practice Address - Country:US
Practice Address - Phone:419-878-8312
Practice Address - Fax:419-878-8844
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3256111N00000X
MI2301008528111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6114246440A00OtherANTHEM BLUE CROSS BLUE SH
OH7580510OtherAETNA
OH2356445Medicaid
OH4090891Medicare PIN