Provider Demographics
NPI:1821403429
Name:BORECKI, JASON ROBERT (LMT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:BORECKI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N STATE PKWY
Mailing Address - Street 2:APT 907
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8112
Mailing Address - Country:US
Mailing Address - Phone:312-656-1979
Mailing Address - Fax:
Practice Address - Street 1:1811 W NORTH AVE STE 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1488
Practice Address - Country:US
Practice Address - Phone:312-656-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227000122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist