Healthcare Provider Details

I. General information

NPI: 1104400738
Provider Name (Legal Business Name): JON P FLYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 S OAK AVE
FREEPORT IL
61032-6445
US

IV. Provider business mailing address

1542 S OAK AVE
FREEPORT IL
61032-6445
US

V. Phone/Fax

Practice location:
  • Phone: 815-291-7743
  • Fax:
Mailing address:
  • Phone: 815-291-7743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5466-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: