Provider Demographics
NPI:1376553628
Name:CHODZEN, JACK (PT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:CHODZEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 N LARAMIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1613
Mailing Address - Country:US
Mailing Address - Phone:773-745-0391
Mailing Address - Fax:773-745-3506
Practice Address - Street 1:2651 N LARAMIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1613
Practice Address - Country:US
Practice Address - Phone:773-745-0391
Practice Address - Fax:773-745-3506
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01627212OtherBLUE CROSS BLUE SHIELD
IL01627212OtherBLUE CROSS BLUE SHIELD