Provider Demographics
NPI:1982904140
Name:FANDERS, JACOB JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:JOHN
Last Name:FANDERS
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 1:18800 W 164TH TER
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-9044
Mailing Address - Country:US
Mailing Address - Phone:402-480-3772
Mailing Address - Fax:
Practice Address - Street 1:12643 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1317
Practice Address - Country:US
Practice Address - Phone:913-643-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor