Provider Demographics
NPI:1386657690
Name:FENNEMA, JASON G (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:G
Last Name:FENNEMA
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 1:1806 W CUYLER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2402
Mailing Address - Country:US
Mailing Address - Phone:773-327-2225
Mailing Address - Fax:
Practice Address - Street 1:1806 W CUYLER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2402
Practice Address - Country:US
Practice Address - Phone:773-327-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor