Provider Demographics
NPI:1881819589
Name:HOUSTON, JACK FORREST
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:FORREST
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 ROBERT LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-7126
Mailing Address - Country:US
Mailing Address - Phone:630-904-2478
Mailing Address - Fax:
Practice Address - Street 1:5TH AVENUE & ROOSEVELT ROAD BUILDING 113
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:708-202-3628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind