Healthcare Provider Details

I. General information

NPI: 1992982664
Provider Name (Legal Business Name): JASON W INGHAM DC SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 N CLARK ST
CHICAGO IL
60657-5775
US

IV. Provider business mailing address

2828 N CLARK ST
CHICAGO IL
60657-5775
US

V. Phone/Fax

Practice location:
  • Phone: 773-868-0347
  • Fax: 773-868-0401
Mailing address:
  • Phone: 773-868-0347
  • Fax: 773-868-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038008978
License Number StateIL

VIII. Authorized Official

Name: DR. JASON WAYNE INGHAM
Title or Position: PRESIDENT
Credential: D.C.
Phone: 773-868-0347