MEDICARE: DR. JASON WAYNE INGHAM DC, CCSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038008978	IL
2	111NS0005X	Sports Physician Chiropractor	038-008978	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01626851	OTHER	IL	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1295835445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON WAYNE INGHAM DC, CCSP

Provider Business Mailing Address
First Line	:	2828 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5775
Country	:	US
Telephone Number	:	773-868-0347
Fax Number	:	773-868-0401

Provider Business Practice Location Address
First Line	:	2828 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5775
Country	:	US
Telephone Number	:	773-868-0347
Fax Number	:	773-868-0401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/12/2023

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