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General NPI Number Information
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NPI Number | 1306045315
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Entity Type | Organization
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Legal Business Name | JLB,INC
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Dates
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Enumeration Date | 07/11/2007
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Last Update Date | 12/30/2013
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Provider Practice Location Address
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Address Line | 450 MILL ST SUITE 102
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City | FONTANA
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State | WI
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Zip | 53125-1242
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Country | US
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Telephone | 262-275-5005
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Fax |
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Provider Business Mailing Address
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Address Line | 450 MILL ST SUITE 102
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City | FONTANA
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State | WI
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Zip | 53125-1242
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Country | US
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Telephone | 262-275-5005
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Fax | 262-275-5004
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. JEREMY LOGAN BRIA
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Credential | D.C.
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Telephone | 262-325-7195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4188-012
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License Number State | WI
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