Provider Demographics
NPI:1053031062
Name:FORD, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54492 TURNING LEAF DR
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-8587
Mailing Address - Country:US
Mailing Address - Phone:443-603-8496
Mailing Address - Fax:
Practice Address - Street 1:463646 STATE ROAD 200 STE 7
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-0303
Practice Address - Country:US
Practice Address - Phone:904-849-1089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH-14095111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor