Healthcare Provider Details

I. General information

NPI: 1962587402
Provider Name (Legal Business Name): JERRY L WETTERLING DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N COLLEGE AVE
ST JOSEPH MN
56374-0237
US

IV. Provider business mailing address

PO BOX 237
ST JOSEPH MN
56374-0237
US

V. Phone/Fax

Practice location:
  • Phone: 320-363-4573
  • Fax: 320-363-1314
Mailing address:
  • Phone: 320-363-4573
  • Fax: 320-363-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1386
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: