Provider Demographics
NPI:1982715488
Name:GUNDERSON, JEREMY A (DC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:A
Last Name:GUNDERSON
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 1:506 S BLACKHAWK
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2908
Mailing Address - Country:US
Mailing Address - Phone:815-624-2669
Mailing Address - Fax:815-624-0488
Practice Address - Street 1:506 S BLACKHAWK
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-2908
Practice Address - Country:US
Practice Address - Phone:815-624-2669
Practice Address - Fax:815-624-0488
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U89787Medicare UPIN
ILL91200Medicare ID - Type Unspecified