Provider Demographics
NPI:1033434931
Name:ILLMAN, JONATHAN (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:ILLMAN
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 1:2350 17TH AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-1737
Mailing Address - Country:US
Mailing Address - Phone:303-651-7003
Mailing Address - Fax:
Practice Address - Street 1:2350 17TH AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-1737
Practice Address - Country:US
Practice Address - Phone:303-651-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6511111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor