Provider Demographics
NPI:1295835445
Name:INGHAM, JASON WAYNE (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WAYNE
Last Name:INGHAM
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5775
Mailing Address - Country:US
Mailing Address - Phone:773-868-0347
Mailing Address - Fax:773-868-0401
Practice Address - Street 1:2828 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5775
Practice Address - Country:US
Practice Address - Phone:773-868-0347
Practice Address - Fax:773-868-0401
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008978111N00000X
IL038-008978111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01626851OtherBLUE CROSS BLUE SHEILD
IL210264Medicare ID - Type Unspecified