Provider Demographics
NPI:1306127733
Name:GULLETT, JARED MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:GULLETT
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 1:2137 E MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-3708
Mailing Address - Country:US
Mailing Address - Phone:618-544-3939
Mailing Address - Fax:618-544-2929
Practice Address - Street 1:2137 E MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-3708
Practice Address - Country:US
Practice Address - Phone:618-544-3939
Practice Address - Fax:618-544-2929
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012013111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor