Provider Demographics
NPI:1427144260
Name:KNODERER, JEFFREY KENT (DC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KENT
Last Name:KNODERER
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 1:217 NORTH MAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365
Mailing Address - Country:US
Mailing Address - Phone:937-492-0028
Mailing Address - Fax:937-492-7882
Practice Address - Street 1:217 NORTH MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365
Practice Address - Country:US
Practice Address - Phone:937-492-0028
Practice Address - Fax:937-492-7882
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0450239Medicaid
OH0450239Medicaid