Healthcare Provider Details

I. General information

NPI: 1568732360
Provider Name (Legal Business Name): JARED J DESTRO DC, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13963 RAISED ANTLER CIR
MIDLOTHIAN VA
23112-2005
US

IV. Provider business mailing address

13963 RAISED ANTLER CIR
MIDLOTHIAN VA
23112-2005
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4800
  • Fax:
Mailing address:
  • Phone: 804-748-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556968
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: