Provider Demographics
NPI:1992881551
Name:ADRIAN, JACK DALE (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DALE
Last Name:ADRIAN
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 1:2850 S COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-9312
Mailing Address - Country:US
Mailing Address - Phone:937-339-5556
Mailing Address - Fax:937-339-5550
Practice Address - Street 1:2850 S COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-9312
Practice Address - Country:US
Practice Address - Phone:937-339-5556
Practice Address - Fax:937-339-5550
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6419330001Medicare NSC