Provider Demographics
NPI:1902971575
Name:FELTS, JERRY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LYNN
Last Name:FELTS
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 1:1100 W BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1700
Mailing Address - Country:US
Mailing Address - Phone:618-993-2810
Mailing Address - Fax:618-993-4086
Practice Address - Street 1:1100 W BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1700
Practice Address - Country:US
Practice Address - Phone:618-993-2810
Practice Address - Fax:618-993-4086
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038003459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038003459Medicaid
T36170Medicare UPIN
29934Medicare ID - Type Unspecified