Healthcare Provider Details

I. General information

NPI: 1154248045
Provider Name (Legal Business Name): JONAH KOELLING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 WILLOW SPRINGS RD
LA GRANGE IL
60525-2600
US

IV. Provider business mailing address

3047 N OAKLEY AVE
CHICAGO IL
60618-7997
US

V. Phone/Fax

Practice location:
  • Phone: 708-245-3988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051.294767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: