Provider Demographics
NPI:1720084338
Name:FONKE, JEROME EARL (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:EARL
Last Name:FONKE
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 1:205 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3409
Mailing Address - Country:US
Mailing Address - Phone:910-484-5999
Mailing Address - Fax:910-484-2523
Practice Address - Street 1:305 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3410
Practice Address - Country:US
Practice Address - Phone:910-484-5999
Practice Address - Fax:910-484-2523
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1875111N00000X
GACHIR004818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC350047272OtherRAILROAD MEDICARE
NC890823WMedicaid
NC0840GOtherBCBS
NC350047272OtherRAILROAD MEDICARE
NC890823WMedicaid