MEDICARE: DR. JORDAN LEASURE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	38010764	IL

General Provider Information

NPI Number	:	1568563054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN LEASURE D.C.

Provider Business Mailing Address
First Line	:	112 LAKE ST
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1812
Country	:	US
Telephone Number	:	847-362-4476
Fax Number	:	847-367-5339

Provider Business Practice Location Address
First Line	:	112 LAKE ST
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1812
Country	:	US
Telephone Number	:	847-542-4476
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	03/18/2013

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