Provider Demographics
NPI:1588773469
Name:JERNIGAN, JAMES MATTHEW (DC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:MATTHEW
Last Name:JERNIGAN
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 1:4830 SOUTH FWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-3901
Mailing Address - Country:US
Mailing Address - Phone:817-926-0012
Mailing Address - Fax:817-927-0533
Practice Address - Street 1:4830 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-3901
Practice Address - Country:US
Practice Address - Phone:817-926-0012
Practice Address - Fax:817-927-0533
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601782OtherBCBS PROVIDER NUMBER