Healthcare Provider Details

I. General information

NPI: 1205217783
Provider Name (Legal Business Name): JARROD THACKER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26317 US HIGHWAY 119 N
BELFRY KY
41514-7417
US

IV. Provider business mailing address

26317 US HIGHWAY 119 N
BELFRY KY
41514-7417
US

V. Phone/Fax

Practice location:
  • Phone: 606-519-3543
  • Fax:
Mailing address:
  • Phone: 606-519-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5465
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: