Provider Demographics
NPI:1104804160
Name:COLE, JONATHAN RAYMOND (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:RAYMOND
Last Name:COLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 ADAM DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-3901
Mailing Address - Country:US
Mailing Address - Phone:660-646-1377
Mailing Address - Fax:660-646-3314
Practice Address - Street 1:803 ADAM DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3901
Practice Address - Country:US
Practice Address - Phone:660-646-1377
Practice Address - Fax:660-646-3314
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT30E158Medicare ID - Type Unspecified
MOV06853Medicare UPIN