Provider Demographics
NPI:1619137502
Name:BUSSELL, JASON MICHAEL (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:BUSSELL
Suffix:
Gender:M
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 1/2 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2826
Mailing Address - Country:US
Mailing Address - Phone:847-251-5225
Mailing Address - Fax:847-251-5456
Practice Address - Street 1:415 1/2 4TH ST
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2826
Practice Address - Country:US
Practice Address - Phone:847-251-5225
Practice Address - Fax:847-251-5456
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000436171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist