Provider Demographics
NPI:1871272484
Name:WALLERICH, JAISA ANN WILLIAMS (DC)
Entity type:Individual
Prefix:DR
First Name:JAISA
Middle Name:ANN WILLIAMS
Last Name:WALLERICH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:JAISA
Other - Middle Name:ANN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8375 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8678 EAGLE CREEK CIR
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-4400
Practice Address - Country:US
Practice Address - Phone:952-432-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor