Provider Demographics
NPI:1679667349
Name:WOTTRICH, JEREL KENNETH SR (DC)
Entity type:Individual
Prefix:DR
First Name:JEREL
Middle Name:KENNETH
Last Name:WOTTRICH
Suffix:SR
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 1:2121 E OLTORF SUITE 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741
Mailing Address - Country:US
Mailing Address - Phone:512-448-1012
Mailing Address - Fax:512-448-2706
Practice Address - Street 1:2121 E OLTORF SUITE 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741
Practice Address - Country:US
Practice Address - Phone:512-448-1012
Practice Address - Fax:512-448-2706
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC2911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT16749Medicare UPIN
TX601163Medicare ID - Type Unspecified