Provider Demographics
NPI:1417975533
Name:WHITACRE, JASON RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RYAN
Last Name:WHITACRE
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 1:7 SUBURBAN DR
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2938
Mailing Address - Country:US
Mailing Address - Phone:618-684-3344
Mailing Address - Fax:618-684-2216
Practice Address - Street 1:1200 LOCUST ST
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2121
Practice Address - Country:US
Practice Address - Phone:618-684-3344
Practice Address - Fax:618-684-2216
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0003932012OtherBCBS
ILU90278Medicare UPIN
IL201834Medicare ID - Type Unspecified