Provider Demographics
NPI:1588717938
Name:JEROME, MARK WARREN (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WARREN
Last Name:JEROME
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 1:1504 51ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55430-3462
Mailing Address - Country:US
Mailing Address - Phone:612-501-1492
Mailing Address - Fax:
Practice Address - Street 1:33 HAMLINE AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2231
Practice Address - Country:US
Practice Address - Phone:651-690-0866
Practice Address - Fax:651-690-0031
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3964111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor