Provider Demographics
NPI:1548507437
Name:DOUGLAS, JERICA LYNN (DC)
Entity type:Individual
Prefix:DR
First Name:JERICA
Middle Name:LYNN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3602
Mailing Address - Country:US
Mailing Address - Phone:315-681-4422
Mailing Address - Fax:315-681-4719
Practice Address - Street 1:156 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3602
Practice Address - Country:US
Practice Address - Phone:315-681-4422
Practice Address - Fax:315-681-4719
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012415111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor