Provider Demographics
NPI:1003914342
Name:MARTIN, JACK RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:RICHARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST SOUTH STREET
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119
Mailing Address - Country:US
Mailing Address - Phone:630-661-1026
Mailing Address - Fax:
Practice Address - Street 1:1601 EAST MAIN STREET
Practice Address - Street 2:SUITE 1B
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174
Practice Address - Country:US
Practice Address - Phone:630-377-4955
Practice Address - Fax:630-377-4958
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4532187OtherBC/BS
ILT37602Medicare UPIN
ILK07518Medicare PIN