Provider Demographics
NPI:1215786835
Name:VINCENT, JERRY BRIAN JR (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:BRIAN
Last Name:VINCENT
Suffix:JR
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 1:780 E IRVING PARK RD STE 2W
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-4343
Mailing Address - Country:US
Mailing Address - Phone:706-728-5109
Mailing Address - Fax:
Practice Address - Street 1:199 S ADDISON RD STE 106
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1978
Practice Address - Country:US
Practice Address - Phone:630-766-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.014151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor