Healthcare Provider Details

I. General information

NPI: 1679620306
Provider Name (Legal Business Name): SCOTT JASON SPENCER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W RANDOLPH ST 1205
CHICAGO IL
60606-1867
US

IV. Provider business mailing address

205 W RANDOLPH ST 1205
CHICAGO IL
60606-1867
US

V. Phone/Fax

Practice location:
  • Phone: 312-265-6908
  • Fax: 312-264-0347
Mailing address:
  • Phone: 312-265-6908
  • Fax: 312-264-0347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038009369
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: