Provider Demographics
NPI:1720806854
Name:BOYLE, JACK THEODORE (DC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:THEODORE
Last Name:BOYLE
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 1:2513 152ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5574
Mailing Address - Country:US
Mailing Address - Phone:425-786-1415
Mailing Address - Fax:
Practice Address - Street 1:2513 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5574
Practice Address - Country:US
Practice Address - Phone:425-786-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61609487111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician