Provider Demographics
NPI:1437283611
Name:LOOSE, JENNIFER (DC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LOOSE
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 1:10441 AUBURN COURT
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142
Mailing Address - Country:US
Mailing Address - Phone:847-669-5183
Mailing Address - Fax:
Practice Address - Street 1:900 PYOTT ROAD
Practice Address - Street 2:SUITE #108
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-356-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04280Medicare ID - Type Unspecified