Healthcare Provider Details

I. General information

NPI: 1699787010
Provider Name (Legal Business Name): JEREMIAH WESLEY CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 06/14/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9010 R.G. SKINNER PKWY
JACKSONVILLE FL
32256-4157
US

IV. Provider business mailing address

9010 R G SKINNER PKWY
JACKSONVILLE FL
32256-7280
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-2703
  • Fax: 904-619-2837
Mailing address:
  • Phone: 904-619-2703
  • Fax: 904-619-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008062
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCH9264
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: