Healthcare Provider Details

I. General information

NPI: 1174639686
Provider Name (Legal Business Name): JEFFREY A PENCE DC CCSP CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 AGENCY ST
BURLINGTON IA
52601-1908
US

IV. Provider business mailing address

3115 AGENCY ST
BURLINGTON IA
52601-1908
US

V. Phone/Fax

Practice location:
  • Phone: 319-752-1460
  • Fax: 319-752-1461
Mailing address:
  • Phone: 319-752-1460
  • Fax: 319-752-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberAO5225
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberAO5225
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: