Provider Demographics
NPI:1487032603
Name:GARDNER, JONATHAN (DC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GARDNER
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 1:1810 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-1807
Mailing Address - Country:US
Mailing Address - Phone:803-796-3750
Mailing Address - Fax:803-796-5202
Practice Address - Street 1:1810 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-1807
Practice Address - Country:US
Practice Address - Phone:803-796-3750
Practice Address - Fax:803-796-5202
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4032DC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor