Healthcare Provider Details

I. General information

NPI: 1578660593
Provider Name (Legal Business Name): JASON L SERPE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RIVERSIDE DR STE 2100
BOURBONNAIS IL
60914-5004
US

IV. Provider business mailing address

400 RIVERSIDE DR STE 2100
BOURBONNAIS IL
60914-5004
US

V. Phone/Fax

Practice location:
  • Phone: 815-935-2991
  • Fax: 815-932-9659
Mailing address:
  • Phone: 815-935-2991
  • Fax: 815-932-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005003
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005003
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: