Provider Demographics
NPI:1508511403
Name:LI, JIA
Entity Type:Individual
Prefix:
First Name:JIA
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W CHESTNUT ST APT 3501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3459
Mailing Address - Country:US
Mailing Address - Phone:860-328-6854
Mailing Address - Fax:
Practice Address - Street 1:1111 W MADISON ST STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2055
Practice Address - Country:US
Practice Address - Phone:860-328-6854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001594171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist