Provider Demographics
NPI:1902935166
Name:DAVIES-KERN, JILL BETH (DC)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:BETH
Last Name:DAVIES-KERN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:BETH
Other - Last Name:DAVIES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:709 S ONEIDA ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2475
Mailing Address - Country:US
Mailing Address - Phone:920-405-1010
Mailing Address - Fax:
Practice Address - Street 1:709 S ONEIDA ST
Practice Address - Street 2:SUITE 3
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2475
Practice Address - Country:US
Practice Address - Phone:920-405-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1841-012111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI680625764016OtherANTHEM BLUE CROSS BLUE SH