Provider Demographics
NPI:1306989884
Name:WEATHERS, JIMMIE E JR (DC)
Entity type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:E
Last Name:WEATHERS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JIM
Other - Middle Name:E
Other - Last Name:WEATHERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:3805 E MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-762-9444
Mailing Address - Fax:630-762-8280
Practice Address - Street 1:3805 E. MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-762-9444
Practice Address - Fax:630-762-8280
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008093111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU67798Medicare UPIN