Provider Demographics
NPI:1144224734
Name:TALLEY, JASON R (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:TALLEY
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 1:3100 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-5185
Mailing Address - Country:US
Mailing Address - Phone:618-451-2874
Mailing Address - Fax:618-451-2858
Practice Address - Street 1:2025 EDISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4514
Practice Address - Country:US
Practice Address - Phone:618-451-2874
Practice Address - Fax:618-451-2858
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4400069OtherUNITED HEALTH CARE
IL442971OtherHEALTHLINK
IL350054835OtherRAILROAD MEDICARE
IL6026195OtherBLUE CROSS BLUE SHIELD
ILU81510OtherMERCY
IL038009072Medicaid