Provider Demographics
NPI:1427026533
Name:WULF, JASON EMIL (LATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:EMIL
Last Name:WULF
Suffix:
Gender:M
Credentials:LATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 SEARLE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2867
Mailing Address - Country:US
Mailing Address - Phone:309-452-8352
Mailing Address - Fax:
Practice Address - Street 1:211 HORTON FIELDHOUSE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-0001
Practice Address - Country:US
Practice Address - Phone:309-438-3284
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL96002168174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist