Provider Demographics
NPI:1053372441
Name:GILLESPIE, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:GILLESPIE
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 1:22 PAQUIN AVE
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-2113
Mailing Address - Country:US
Mailing Address - Phone:207-571-4004
Mailing Address - Fax:207-571-4004
Practice Address - Street 1:22 PAQUIN AVE
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005
Practice Address - Country:US
Practice Address - Phone:207-571-4004
Practice Address - Fax:207-571-4004
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1389111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200361964OtherEIN
ME200361964OtherEIN