=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437458304
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON SCOTT OZBOURN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2011
-----------------------------------------------------
Last Update Date | 11/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 SHERIDAN DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62812-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-927-2822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 TRANSCRAFT DR
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62906-2114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-833-2179
-----------------------------------------------------
Fax | 618-833-4596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 038011964
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.011964
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------