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General NPI Number Information
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NPI Number | 1194132340
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Entity Type | Organization
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Legal Business Name | PRO-ACTIVE CHIROPRACTIC & PHYSIOTHERAPY
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Dates
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Enumeration Date | 07/21/2014
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Last Update Date | 07/21/2014
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Provider Practice Location Address
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Address Line | 3430 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60657-1195
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Country | US
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Telephone | 773-697-4142
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Fax |
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Provider Business Mailing Address
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Address Line | 3430 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60657-1195
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Country | US
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Telephone | 773-697-4142
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. JASON JARED
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Credential | D.O.
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Telephone | 773-697-4142
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 038011033
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License Number State | IL
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