Provider Demographics
NPI:1730191834
Name:KERSHAW, JEROME RANDALL (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:RANDALL
Last Name:KERSHAW
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 1:2700 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-449-2000
Mailing Address - Fax:626-449-2043
Practice Address - Street 1:2700 E FOOTHILL BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-449-2000
Practice Address - Fax:626-449-2043
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T17540Medicare UPIN
CADC13573Medicare ID - Type Unspecified