Provider Demographics
NPI:1407131386
Name:MA, JENNIFER (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-889-6453
Mailing Address - Fax:
Practice Address - Street 1:200 EAST ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148
Practice Address - Country:US
Practice Address - Phone:630-889-6453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03801617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor