Provider Demographics
NPI:1366471815
Name:STOUT, JEFFREY K (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:K
Last Name:STOUT
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 1:214 S LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3008
Mailing Address - Country:US
Mailing Address - Phone:309-454-8622
Mailing Address - Fax:309-454-8626
Practice Address - Street 1:214 S LINDEN ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3008
Practice Address - Country:US
Practice Address - Phone:309-454-8622
Practice Address - Fax:309-454-8626
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5715400OtherBLUE CROSS BLUE SHIELD
IL006591OtherHEALTH ALLIANCE
IL5715400OtherBLUE CROSS BLUE SHIELD
ILT38559Medicare UPIN
IN350016758Medicare PIN