Provider Demographics
NPI:1174629596
Name:MARMO, JEREMY JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOHN
Last Name:MARMO
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 1:301 N WHITE ST
Mailing Address - Street 2:SUITE DD
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1456
Mailing Address - Country:US
Mailing Address - Phone:815-469-9270
Mailing Address - Fax:815-469-9544
Practice Address - Street 1:301 N WHITE ST
Practice Address - Street 2:SUITE DD
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1456
Practice Address - Country:US
Practice Address - Phone:815-469-9270
Practice Address - Fax:815-469-9544
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206152Medicare ID - Type UnspecifiedMEDICARE
ILU94291Medicare UPIN