MEDICARE: DR. JEFFREY DETERICK WILCOCK DC

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	7363	AZ

General Provider Information

NPI Number	:	1912172883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY DETERICK WILCOCK DC

Provider Business Mailing Address
First Line	:	1726 E THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-7604
Country	:	US
Telephone Number	:	602-222-9595
Fax Number	:	602-234-1211

Provider Business Practice Location Address
First Line	:	420 E SOUTHERN SUITE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204
Country	:	US
Telephone Number	:	480-223-9595
Fax Number	:	480-833-3299

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

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	08/13/2021

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