Basic Information
| Provider Information | |||||||||
| NPI: | 1518175108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINERNY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4701 AUBURN WAY N | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980021312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538502225 | ||||||||
| FaxNumber: | 2538505757 | ||||||||
| Practice Location | |||||||||
| Address1: | 4701 AUBURN WAY N | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980021312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538502225 | ||||||||
| FaxNumber: | 2538505757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH0002412 | WA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 8377947 | 05 | WA | MEDICAID | 55469 | 01 | WA | DEPT OF L&I | OTHER |