Provider Demographics
NPI:1518033646
Name:HETHER, JAMES JEREMY (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JEREMY
Last Name:HETHER
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 1:1301 HARMS WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-5260
Mailing Address - Country:US
Mailing Address - Phone:386-304-6683
Mailing Address - Fax:386-734-6924
Practice Address - Street 1:2719 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7005
Practice Address - Country:US
Practice Address - Phone:386-734-0702
Practice Address - Fax:386-734-6924
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH7306OtherSTATE LICENCE #
45692OtherBLUE CROSS BLUE SHIELD #
45692OtherBLUE CROSS BLUE SHIELD #
FLE8703ZMedicare ID - Type Unspecified