Provider Demographics
NPI:1740611268
Name:DOMICO, JASON (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DOMICO
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 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:STE 301N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-320-6400
Mailing Address - Fax:630-701-1007
Practice Address - Street 1:2210 CAMDEN CT
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1272
Practice Address - Country:US
Practice Address - Phone:630-468-1820
Practice Address - Fax:630-701-1007
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012495111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor