MEDICARE: DR. JEREMY TODD JERNIGAN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1065	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	342005143	OTHER	MS	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1194864165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY TODD JERNIGAN D.C.

Provider Business Mailing Address
First Line	:	2045 E PASS RD STE B
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3761
Country	:	US
Telephone Number	:	228-896-7574
Fax Number	:	228-896-7579

Provider Business Practice Location Address
First Line	:	2045 E PASS RD STE B
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3761
Country	:	US
Telephone Number	:	228-896-7574
Fax Number	:	228-896-7579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	03/15/2023

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