Provider Demographics
NPI:1003993148
Name:POPP, JASON C (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:POPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N 2ND ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1717
Mailing Address - Country:US
Mailing Address - Phone:815-562-3784
Mailing Address - Fax:815-561-3142
Practice Address - Street 1:900 N 2ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1717
Practice Address - Country:US
Practice Address - Phone:815-562-3784
Practice Address - Fax:815-561-3142
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104525Medicaid
IL036104525Medicaid
ILL88188Medicare PIN