Provider Demographics
NPI:1730228248
Name:UTTERBACK, JACOB HEDGES (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:HEDGES
Last Name:UTTERBACK
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 1:140 W ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4023
Mailing Address - Country:US
Mailing Address - Phone:314-965-8084
Mailing Address - Fax:314-965-8612
Practice Address - Street 1:140 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-4023
Practice Address - Country:US
Practice Address - Phone:314-965-8084
Practice Address - Fax:314-965-8612
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007000279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO791611OtherHEALTHLINK
MO990001813Medicare PIN
MO260961813Medicare UPIN