Healthcare Provider Details

I. General information

NPI: 1215211495
Provider Name (Legal Business Name): JAQUES CHIROPRACTIC L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 SOUTHARD TRCE
CUMMING GA
30040-6343
US

IV. Provider business mailing address

6010 SOUTHARD TRCE
CUMMING GA
30040-6343
US

V. Phone/Fax

Practice location:
  • Phone: 678-947-3316
  • Fax: 678-947-3317
Mailing address:
  • Phone: 678-947-3316
  • Fax: 678-947-3317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008843
License Number StateGA

VIII. Authorized Official

Name: DR. JEREMY RYAN JAQUES
Title or Position: OWNER
Credential: D.C.
Phone: 678-947-3316