Provider Demographics
NPI:1386673705
Name:FOX, JERRY WAYNE (DC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:FOX
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 1:1004 LINCOLN ST
Mailing Address - Street 2:P.O. BOX 308
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-1502
Mailing Address - Country:US
Mailing Address - Phone:785-456-8657
Mailing Address - Fax:785-456-8882
Practice Address - Street 1:1004 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-1502
Practice Address - Country:US
Practice Address - Phone:785-456-8657
Practice Address - Fax:785-456-8882
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS014220Medicare ID - Type Unspecified
KSU5099Medicare UPIN