Provider Demographics
NPI:1235325200
Name:DICKHUT, JEFFREY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:DICKHUT
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 1:1603 VISA DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2151
Mailing Address - Country:US
Mailing Address - Phone:309-268-9000
Mailing Address - Fax:309-268-9003
Practice Address - Street 1:1603 VISA DR
Practice Address - Street 2:SUITE 3
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2151
Practice Address - Country:US
Practice Address - Phone:309-268-9000
Practice Address - Fax:309-268-9003
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732057OtherBLUE CROSS BLUE SHIELD
ILU91716Medicare UPIN