Provider Demographics
NPI:1063559102
Name:JEFFREY, KYLIE NEIDERHISER (DC)
Entity type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:NEIDERHISER
Last Name:JEFFREY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:
Other - Last Name:NEIDERHISER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1611 COLUMBIA BLVD
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8862
Mailing Address - Country:US
Mailing Address - Phone:570-389-1901
Mailing Address - Fax:570-389-0469
Practice Address - Street 1:1611 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8862
Practice Address - Country:US
Practice Address - Phone:570-389-1901
Practice Address - Fax:570-389-0469
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019225790001Medicaid
PA1019225790001Medicaid