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General NPI Number Information
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NPI Number | 1114116522
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Entity Type | Organization
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Legal Business Name | RAVENSWOOD HEALTH CENTER, P.C.
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Dates
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Enumeration Date | 10/22/2007
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 4256 N. RAVENSWOOD AVE. SUITE NUMBER 101
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City | CHICAGO
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State | IL
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Zip | 60613
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Country | US
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Telephone | 773-327-2225
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Fax | 773-327-7554
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Provider Business Mailing Address
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Address Line | 4256 N. RAVENSWOOD AVE, SUITE NUMBER 101
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City | CHICAGO
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State | IL
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Zip | 60613
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Country | US
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Telephone | 773-327-2225
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Fax | 773-327-7554
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. JASON G. FENNEMA
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Credential | D.C.
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Telephone | 773-327-2225
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070009516
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038-008864
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License Number State | IL
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