Provider Demographics
NPI:1790011740
Name:LITTLE, JON SCOTT (IDC)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:SCOTT
Last Name:LITTLE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001A SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-5230
Mailing Address - Country:US
Mailing Address - Phone:847-688-2469
Mailing Address - Fax:
Practice Address - Street 1:3001A SIXTH STREET
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-5230
Practice Address - Country:US
Practice Address - Phone:847-688-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman