Provider Demographics
NPI:1952556037
Name:CRAIG, JEROME GAVIN (DC, LMT)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:GAVIN
Last Name:CRAIG
Suffix:
Gender:M
Credentials:DC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2435
Mailing Address - Country:US
Mailing Address - Phone:503-288-4454
Mailing Address - Fax:503-288-1783
Practice Address - Street 1:118 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2435
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:503-288-1783
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11637171W00000X
OR3896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171W00000XOther Service ProvidersContractor