Healthcare Provider Details

I. General information

NPI: 1891053534
Provider Name (Legal Business Name): JACOB BERNARD MATRILLE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 W ADDISON ST
CHICAGO IL
60618-4635
US

IV. Provider business mailing address

2625 BUTTERFIELD RD STE 301N
OAK BROOK IL
60523-1234
US

V. Phone/Fax

Practice location:
  • Phone: 773-273-2901
  • Fax:
Mailing address:
  • Phone: 630-320-6400
  • Fax: 630-701-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.012149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: