Provider Demographics
NPI:1447317391
Name:REPOLE, JON MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:REPOLE
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 1:213 AFTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5410
Mailing Address - Country:US
Mailing Address - Phone:516-652-3262
Mailing Address - Fax:904-886-9804
Practice Address - Street 1:10950 SAN JOSE BLVD STE 14
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-6671
Practice Address - Country:US
Practice Address - Phone:904-268-6568
Practice Address - Fax:904-886-9804
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8960111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88156Medicare UPIN
FL89590YMedicare ID - Type Unspecified