Healthcare Provider Details

I. General information

NPI: 1265987440
Provider Name (Legal Business Name): JONATHAN BACOS STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HURON ST SUITE 1-200
CHICAGO IL
60611-2909
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 414-955-4578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberB22043894236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: