Provider Demographics
NPI:1386170793
Name:KORNETZKE, JACOB WILLIAM (DC, MS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WILLIAM
Last Name:KORNETZKE
Suffix:
Gender:M
Credentials:DC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9748
Mailing Address - Country:US
Mailing Address - Phone:262-644-8488
Mailing Address - Fax:
Practice Address - Street 1:100 E COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9748
Practice Address - Country:US
Practice Address - Phone:262-644-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5279-12111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition