Provider Demographics
NPI:1124082599
Name:VANDERVORT, JACK K (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:K
Last Name:VANDERVORT
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 1:11581 STATE HWY 98
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-7321
Mailing Address - Country:US
Mailing Address - Phone:814-336-3434
Mailing Address - Fax:814-337-8767
Practice Address - Street 1:11581 STATE HWY 98
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-7321
Practice Address - Country:US
Practice Address - Phone:814-336-3434
Practice Address - Fax:814-337-8767
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001577L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006316630002Medicaid
PA0006316630002Medicaid