Provider Demographics
NPI:1902883416
Name:DEXTER, JEFFREY RUSSELL (DC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RUSSELL
Last Name:DEXTER
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 1:325 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2002
Mailing Address - Country:US
Mailing Address - Phone:740-376-9944
Mailing Address - Fax:740-376-0094
Practice Address - Street 1:325 4TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2002
Practice Address - Country:US
Practice Address - Phone:740-376-9944
Practice Address - Fax:740-376-0094
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1730111N00000X
WV762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459294Medicaid
000000120157OtherANTHEM
OH0459294Medicaid
U28145Medicare UPIN