MEDICARE: JAMES MATTHEW JERNIGAN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4462	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	601782	OTHER	TX	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1588773469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES MATTHEW JERNIGAN D.C.

Provider Business Mailing Address
First Line	:	4830 SOUTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3901
Country	:	US
Telephone Number	:	817-926-0012
Fax Number	:	817-927-0533

Provider Business Practice Location Address
First Line	:	4830 SOUTH FWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76115-3901
Country	:	US
Telephone Number	:	817-926-0012
Fax Number	:	817-927-0533

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	11/25/2008

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