Provider Demographics
NPI:1104993658
Name:TYJESKI, JEROME E (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:E
Last Name:TYJESKI
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 1:119 E MACKIE ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2031
Mailing Address - Country:US
Mailing Address - Phone:920-885-3020
Mailing Address - Fax:920-885-3024
Practice Address - Street 1:119 E MACKIE ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2031
Practice Address - Country:US
Practice Address - Phone:920-885-3020
Practice Address - Fax:920-885-3024
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38861200Medicaid
WI391801604OtherFEDERAL TAX ID NUMBER
WIW10103Medicare UPIN
WI391801604OtherFEDERAL TAX ID NUMBER
WI391801604011Medicare UPIN
WI38861200Medicaid