Healthcare Provider Details

I. General information

NPI: 1083116404
Provider Name (Legal Business Name): JASON WENING CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE STE 301
CHICAGO IL
60657-5084
US

IV. Provider business mailing address

1S376 SUMMIT AVE CRT E
OAKBROOK TERRACE IL
60181-3985
US

V. Phone/Fax

Practice location:
  • Phone: 773-472-3663
  • Fax: 773-472-3668
Mailing address:
  • Phone: 630-705-4092
  • Fax: 630-424-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000213
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number213.000280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: