Provider Demographics
NPI:1124147806
Name:CARPENTER, JERRY A (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:C
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:910 KEHRS MILL RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:636-391-1611
Mailing Address - Fax:636-391-5856
Practice Address - Street 1:910 KEHRS MILL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-391-1611
Practice Address - Fax:636-391-5856
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000000408712OtherBLUE CROSS GROUP PIN
MO4648OtherBLUE CROSS PIN
MO000000408712OtherBLUE CROSS GROUP PIN
MO4648OtherBLUE CROSS PIN