MEDICARE: DR. JASON G FENNEMA D.C.

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	038-010696	IL

General Provider Information

NPI Number	:	1386657690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON G FENNEMA D.C.

Provider Business Mailing Address
First Line	:	1806 W CUYLER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2402
Country	:	US
Telephone Number	:	773-327-2225
Fax Number	:

Provider Business Practice Location Address
First Line	:	1806 W CUYLER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2402
Country	:	US
Telephone Number	:	773-327-2225
Fax Number	:

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	03/07/2008

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