Provider Demographics
NPI:1194864165
Name:JERNIGAN, JEREMY TODD (DC)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:TODD
Last Name:JERNIGAN
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 1:2045 E PASS RD STE B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3761
Mailing Address - Country:US
Mailing Address - Phone:228-896-7574
Mailing Address - Fax:228-896-7579
Practice Address - Street 1:2045 E PASS RD STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3761
Practice Address - Country:US
Practice Address - Phone:228-896-7574
Practice Address - Fax:228-896-7579
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS342005143OtherTAX IDENTIFICATION NUMBER