Provider Demographics
NPI:1447974423
Name:EBERTH, JAKE (DC (CHIROPRACTIC))
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:EBERTH
Suffix:
Gender:M
Credentials:DC (CHIROPRACTIC)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1763
Mailing Address - Country:US
Mailing Address - Phone:585-698-0400
Mailing Address - Fax:
Practice Address - Street 1:765 CENTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1763
Practice Address - Country:US
Practice Address - Phone:585-698-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013662111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor